Align Sports Massage

Confidential Intake Form

Thank you for filling this out completely so I can better create a individualized session to help you feel better today.

Name

First Name

Last Name

Phone

Address

How did you hear about Align Sports Massage?

Have you had a professional massage before?

If yes, how often do you receive massages?

If yes, do you have a style or pressure preference?

What type of massage are you seeking today? Neuromuscular Therapy, Sports Massage/Deep Tissue, Relaxation?

What are your common areas of pain or tension? Please list specific areas of the body you would like to concentrate on during the session

List all surgeries, injuries, & accidents with year of occurrence including acute or chronic, frequency and known triggers for your pain or discomfort

Are you currently under the care of a physician or health professional? For what conditions?

Please list any conditions that you have had or currently have

Cancellation and No Show Policy: The full value of the service will be charged for lateness, cancellations, no-shows, or changes received within 24 hours of a scheduled appointment. Thank you for your understanding and compliance.

Release: I, the client, understand that the massage I receive is provided for basic purposes of relaxation and relief of muscular tension. I take full responsibility for informing my therapist of any condition that could effect this session. If I experience any pain or discomfort during my sessions, I will immediately inform the therapist so that the pressure and or strokes can be adjusted to my level of comfort. I understand that my therapist is not qualified to perform adjustments, diagnose, or treat physical or mental illness. Because massage should not be performed under certain medical conditions, I have listed all my known medical conditions and answered all questions honestly. If I have specific medical condition or specific symptoms, massage maybe contraindicated and a referral from my doctor may be required prior to service being provided. I agree to keep my therapist updated on any changes to my health and understand that there should be no liability on the therapist's part should I fail to do so.

Client Signature

Date