Massage Intake Form

If you are pregnant, please be aware that *We do not offer massage in the first trimester of pregnancy.

Contraindications for hot stone massage: Blood clots or previous history of blood clots Easily bruised and find bruising painful Currently have a known cancer or are receiving treatment for cancer Conditions that compromise the immune system Diabetic Any heart conditions High or low blood pressure Areas of inflamed or damaged skin Pregnant Sores, blemishes, or open wounds Neuropathy Recovering from recent surgery Varicose veins

I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given 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 therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so. Consent to Treatment of Minor: IF UNDER THE AGE OF 18, PARENT’S/GUARDIAN NAME IS REQUIRED. The consent to treatment of minors must be signed by parent/guardian. CONSENT TO TREATMENT OF MINORS (Please use this portion for consent to provide massage therapy to those less than 18 years old) I (Parent/Guardian) hereby consent Release Well-Being Center to administer massage therapy techniques to my child of dependent as deemed necessary.