Initial Massage Intake

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. I will consult my therapist with any questions or concerns immediately.”

“I do not have any conditions that are contraindicated for massage, wraps or scrubs that would be aggravated by any bodywork.”  

 

“I have stated all medical conditions that I am aware of and will keep my therapist informed of any changes.”  

 

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

 

“I acknowledge that it is my choice to receive massage therapy. I agree to hold Banya 5 harmless for any and all liability that may occur in the performance of any service provided.” 

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

 


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.

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