New Massage Client Consent
Informed Consent (Please read in its entirety and sign below)

I give my consent to participate in the massage program conducted by DPI Adaptive Fitness.

By completing this consent form I understand that I am personally responsible for my actions during my tenure at (DPI) whether in a group format or individual session and that I waive the responsibility of this group (DPI) if I should incur any injury as a result of my own negligence.

I understand the fee schedule to be:
60 minute session-$70
30 minute session-$40

I will be invoiced at completion of session by email. All major credit cards, apple pay, and Checks are accepted.

a 3% service charge will be incurred for all non-cash transactions

Cancellation Policy:

Please notify us of any cancellations within 24 hours of appointment

Repeated cancellations without notice will incur a cancellation fee of $25

I understand that I can schedule directly with trainerjaneu@gmail.com
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Email *
Name *
Physician *
Address *
City *
State *
Zip *
Home Phone *
Work Phone *
Emergency contact: Name and Contact Number *
Occupation
Date of Birth *
MM
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DD
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YYYY
Wear Contacts *
Pregnant? *
If pregnant, what month?
Why are you coming for massage therapy? *
What areas of your body would you like the therapist to focus on? *
Do you have any medical problems such as high blood pressure, allergies, varicose veins, diabetes, phlebitis, cancer, heart condition, infectious/communicable diseases or other significant problems? If so, describe below.
Answer Below:
Date
MM
/
DD
/
YYYY
Doctor
Diagnosis
Treatment
Hospital
Have you had an injury, accident or surgery? Please describe below.
Date
MM
/
DD
/
YYYY
Doctor
Diagnosis
Treatment
Hospital
Describe how the above happened:
Describe any other physical complaints problem areas and cautions: *
Are you currently under the care of a physical therapist *
If so, who?
Are there any factors contributing to tension or stress? *
Are you taking any medications or drugs at this time? *
If Yes, what type?
What are your sports/exercise/recreation activities? *
When did you last have a therapeutic massage?
MM
/
DD
/
YYYY
What type of pressure do you like? *
How did you hear about us? *
Any Additional Comments? *
I certify that the above information is complete and correct. I will keep the massage therapist informed of any changes as they occur
Participant Electronic signature-Print full name to accept informed consent *
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