intake form template for massage therapy

Client Health History and Informed Consent Agreement

Instructions for Use

• Print this document and provide it to the client for completion prior to the commencement of their first session.
• Ensure all sections, particularly the medical history and consent disclosures, are initialed and signed by the client to maintain a valid record.
• Retain the signed original in a secure, confidential file in accordance with local health data privacy regulations.

Parties and Definitions

This agreement is entered into by and between [Massage Therapist/Business Name] ("Practitioner") and the undersigned ("Client").

Client Information: Full Legal Name: [] Date of Birth: [] Phone Number: [] Email Address: [] Emergency Contact Name: [] Emergency Contact Phone: []

Operative Terms

1. Medical History Disclosure: The Client represents that they have provided accurate information regarding their health status, including but not limited to: high blood pressure, heart conditions, pregnancy, recent surgeries, chronic pain, or infectious diseases. The Client agrees to update the Practitioner of any changes to their health status prior to future sessions.

2. Scope of Practice: The Client understands that massage therapy is for the purpose of stress reduction, relief from muscular tension, or improvement of circulation. The Practitioner is not a physician and does not diagnose illness, disease, or any other physical or mental disorder.

3. Informed Consent: The Client understands that they may request the massage be terminated at any time. The Client is responsible for communicating if the pressure or technique is uncomfortable or painful. The Client acknowledges that they have been informed of the potential risks and benefits associated with massage therapy.

4. Professional Boundaries: The Client acknowledges that this is a professional therapeutic environment. Any illicit or suggestive remarks or advances will result in the immediate termination of the session, and the Client will be liable for the full cost of the scheduled service.

5. Cancellation Policy: Appointments must be cancelled at least [] hours in advance. Failure to provide sufficient notice may result in a cancellation fee of $[].

6. Assumption of Risk: The Client voluntarily assumes all risks associated with the massage therapy session and hereby releases the Practitioner from any and all liability for injury or damages arising from the session, except in cases of gross negligence.

Signature and Acknowledgment

I have read and fully understand the terms set forth above. I certify that the information provided by me is true and accurate to the best of my knowledge.

Signature: [] Printed Name: [] Date: [__________]

Legal Disclaimer: This document is a general framework and does not constitute legal advice. Massage therapy regulations vary significantly by jurisdiction; consult with qualified legal counsel to ensure compliance with local, state, and provincial laws regarding health data privacy and professional practice requirements.