mxm new client intake form

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In advance of your first treatment, we ask that you complete this liability waiver and answer a few brief questions.

This form is automatically date/time stamped when you submit.

Email *

Liability Waiver

I understand that massage therapy is provided for stress reduction, relaxation, relief from muscular tension, and improvement of circulation and energy flow.

If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/strokes can be adjusted to my level of comfort. I will not hold my therapist responsible for any pain or discomfort I experience during or after the session.

I understand that the services offered today are not a substitute for medical care. I understand that my therapist is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness.

I affirm that I have notified my therapist of all known medical conditions and injuries.

I agree to inform the therapist of any changes in my health and medical condition. I understand that there shall be no liability on thetherapist’s part should I forget to do so.

I understand that massage is entirely therapeutic and non-sexual in nature.

By signing this release, I hereby waive and release my therapist from any and all liability, past, present, and future relating to massage therapy and bodywork.

I have received the policy statement, and have read and agree to the policies therein.

Please provide your electronic signature, acknowledging you read the above waiver prior to your treatment. In this case, your typed name serves as your signature. *

First + Last Name *

Phone Number (with Area Code) *

Do you have any current injuries or concerns of which we should be aware? *

YES

If yes, please describe:

Please provide the name, contact information and relationship of your emergency contact. (Example: John Doe, 555.555.5555, partner) *

Is there a reason you're seeking massage therapy? We'd love to better understand your needs and/or goals for your treatment.

Thank you so much for taking the time to thoughtfully complete this form.

A copy of your responses will be emailed to the address you provided.

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