Intake Form | Good Sign Massage

Full Name:*

First Last

Date of Birth:

Mobile #:*

Address:

Street Address

Email Address:*

Occupation:

Physician Name:

Emergency Contact Name:

Relationship:

Telephone #:

Are you currently or have you in the past experienced any of the below conditions? Please check all that apply: 

*Please note that a doctor’s note may be required for certain conditions and provided to Good Sign Massage prior to massage treatment.

Do you have any other medical conditions or injuries not listed above?

Medications you are taking:

Is there a specific reason for selecting this treatment?

Relaxation
Muscle Tension

If you choose Muscle Tension, Where?

Client Waiver*

I understand that the treatment or services I receive from Good Sign Massage are not meant to diagnose, prescribe medication for medical or psychological conditions, nor treat for specific medical conditions. I further understand that the treatment should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should consult a physician, chiropractor or another qualified medical specialist for physical or mental ailments of which I am aware. If I experience pain or discomfort during the massage therapy session, I will immediately inform the therapist so that the pressure or technique may be adjusted to my comfort level. I affirm that I have stated all of my known medical conditions and answered all questions honestly.

I agree to keep the massage therapist updated as to any changes in my medical profile and understand there should be no liability on the massage therapist or Good Sign Massage’s part should I fail to do so.
I agree to hold harmless to the massage therapist and employees of Good Sign Massage from and against any liabilities, claims or demands which may be made against them by any personal representative, spouse, or beneficiary arising from the undersigned’s attendance at said sessions or treatments

I agree to the privacy policy.

Client's Signature*

Date Signed

Comments

This field is for validation purposes and should be left unchanged.

Client Intake Form

*Please note that a doctor’s note may be required for certain conditions and provided to Good Sign Massage prior to massage treatment.