Initial Massage Intake Form

In order to plan a session that is safe and effective, we need some general information about your medical history.

PLEASE READ, INITIAL & SIGN AT THE BOTTOM
“I understand the benefits and risks of massage therapy and give my consent for treatment. I will consult my therapist with any questions or concerns immediately.  I understand the therapist reserves the right to refuse services for reasons of safety or should my needs exceed the therapist's knowledge, skill, and abilities or scope of practice.”

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“I do not have any conditions that are contraindicated for massage or bodywork.  I agree to speak with my therapist each session about any concerns, considerations, limitations, exclusions, or alterations/variations I may wish to be addressed/honored during that session.”  

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“I have listed all my known medical conditions and will inform the massage therapist of any change in my physical health between sessions. I understand that a massage therapist neither diagnoses nor prescribes for illness, disease, or any other medical, physical, or emotional disorders.” 

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“I understand that Banya 5 has a no-tolerance policy for any sexual acting-out behavior and agree to adhere to this policy. My therapist has the right to end the session in the event of such behavior.”  

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“If for any reason I feel my well-being is threatened or compromised or if I feel uncomfortable during the session I agree to notify the therapist and management. I acknowledge I have full authority and responsibility regardless of the reason to determine if and when I may want the treatment paused, changed or stopped."

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"I give Banya 5 permission to share this information among it's service providers." 

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"I acknowledge that Banya 5 requires a 24-hour notice for all appointment cancellations.  That failure to provide this notice will result in an automatic charge up to the full amount of the services cancelled."  

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Who will be participating?

Adult    Children

Adult / Guardian Information

Recent accident, injury or surgery, Muscular problems, Circulatory or blood conditions, Diabetes, Neurological condition, Skeletal conditions, Headache, Cancer, previous surgery or disease, previous accidents or other medical conditions.

Sign Here

I have read the above information and guidelines and agree to follow them.