Massage Intake Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Massage Intake Form

Sakinah Irizarry, LMT

Email *

First Name *

Last Name *

Date of Birth *

YYYY

What are your preferred pronouns? *

he/him/his

she/her/hers

they/them/theirs

Other:

Street Address *

Town/City *

State *

Zip Code *

Phone Number *

Referred by

The following information will be used to help plan safe and effective massage sessions. It will be kept confidential. Please answer to the best of your knowledge.

Have you had professional massage before?

Yes

Clear selection

Please state sensitivities to oils, lotions or scents, or say "none"

What are your goals for this session?

Are you currently taking any medications, prescription or over-the-counter?

Yes

Clear selection

If so, please explain

Please select any condition below that applies to you

anxiety/depression

DVT/blood clots

joint replacement or internal fixation

osteoporosis

varicose veins

heart condition

diabetes

recent surgery

epilepsy/seizures

easy bruising

headache/migraine

recent injury

food allergy or sensitivity

high or low blood pressure

circulatory issues

numbness

pregnancy

osteo or rheumatoid arthritis

physical or emotional trauma

Please explain any condition you checked above

Is there any part of your body you prefer not to be touched?

Is there anything else about your health history that you think would be useful for your massage therapist to know?

Consent for Care

If I experience pain or discomfort during any sessions, I will immediately inform the practitioner so the pressure may be adjusted to my level of comfort. I understand massage is not a substitute for medical examination, diagnosis, or treatment and I should see a physician or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand massage practitioners do not perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and nothing communicated in the course of the session should be construed as such. Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so.

Understanding all of this, I give my consent to receive care, by typing my name below. *

Acknowledgement of cancellation policy

The confirmation email you received contains links to cancel/reschedule up to 24 hours before your session. Immediately cancel by phone or text if you are feeling ill or have had extended exposure to someone contagious. There are no fees in the case of sudden illness. No shows and cancellations under 24 hours will be charged the full rate for reasons other than illness. Call or text 845-594-2084 in the event of emergencies. Full policy available at: https://sakinahirizarrylmt.com/policies

Confirm receipt of policies, initial here: *

Airborne viruses, colds and flu

Preventative air quality measures and sanitation protocols have been implemented at this office intended to reduce the spread of airborne viruses, colds or flu. Because massage involves close contact over an extended period of time in a enclosed space, there is an elevated risk of disease transmission. By answering below, you acknowledge you are aware of the risk and give consent to receive a massage at this office.

Understanding the risk of airborne disease transmission, I consent to receive care by typing my name below. *

Send me a copy of my responses.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of Sakinah Irizarry, LMT. Report Abuse

Forms