Massage Intake Form - Crosby Chiropractic & Acupuncture Centre

Massage Intake Form

Massage Intake Form

Name
MM slash DD slash YYYY
Address
Emergency Contact
Have you ever received massage therapy?
Are you currently seeing a healthcare professional?
Please list all medications you are taking
List one medication per line. Click on the + sign to add more.
Do any of the following apply to you today:
Have you had a fever in the last 24 hours of 100°F or above?
Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath?_
Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms?
Have you travelled out of state in the last 14 days?
Please check the conditions that apply to you:
Please indicate any areas of discomfort:
Girl in a jacket



Responses to experience during the massage may include:
  • The need to move/change positions
  • Sighing/Yawning
  • Stomach gurgling
  • Emotional feelings/Memories
  • Falling asleep
I understand massage therapy can be very therapeutic, relaxing, & reduces muscle tension, but is not a substitute for medical examination & treatment.

This is a therapeutic massage and any sexual remarks or advances will terminate the session and I will be liable for full payment.

On occasion, massage should not be done under certain medical conditions; I affirm I have answered all medical questions truthfully.

I understand that, because massage therapy work involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. By signing this form, I acknowledge that I am aware of the risks involved and give consent to receive massage and bodywork from this practitioner.
Clear Signature
MM slash DD slash YYYY