Intake Form - Sasha Peterson

Name

Date of Birth

Emergency Contact Name

Emergency Contact Phone

Have you had a professional massage before?yesno

Are you pregnant?yesno

Reason for initial visit:

List any allergies (especially anything that could be in lotions, oils, creams):

List any major injuries and/or surgeries and approximate dates of each:

I agree that all of the information I have provided is correct:Yes

I understand that massage is not a replacement for medical care and no medical diagnosis will be made. Because massage and bodywork may be a contraindication due to certain medical conditions, I affirm that I have informed the therapist of all known medical conditions and will keep the therapist updated as to any changes in my medical condition going forward. If I experience any pain or discomfort during the session, I will immediately inform the therapist so that the pressure and/ or manipulations, draping, or environment may be adjusted to my comfort level. Any illicit or sexually suggestive comments or actions made by me will result in immediate termination of the session and I am responsible for the full payment. I have read and agree to the terms above:Yes