Massage Client Information

First Namerequired
Last Namerequired
Date of Birthrequired
Phone (Digits Only)required


Emergency Contact Nametextrequireddb save
Contact Relationshiptextoptionalnot save
Contact Phonenumberrequireddb save

Questions for Clients (please provide explanations where necessary)

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Do you have diabetes?

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Do you experience frequent headaches?

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Are you pregnant?

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Do you have arthritis or joint swelling?

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Are you wearing contact lenses or dentures?

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Do you have high blood pressure?

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Are you taking high blood pressure medication?

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Do you have epilepsy or seizures?

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Do you have varicose veins?

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Do you have any contagious diseases?

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Do you have osteoporosis?

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Do you have any allergies?

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Do you bruise easily?

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Any broken bones or major injuries in the past two years?

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Do you have tension or soreness in a specific area?

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Do you have cardiac or circulatory problems?

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Are you sensitive to touch or pressure in any area?

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Have you ever had surgery?

If you answered YES to any of the above, please explain.textoptionalno save

Other medical condition, or are you taking any medications I should know about?textoptionalno save

What is your goal for massage?textoptionalno save

Please take a moment to carefully read the following information and sign where indicated. If you have a specific medical condition or specific symptoms, massage/bodywork may be contraindicated. A referral from your primary care provider may be required prior to service being provided.

I understand that the massage/bodywork 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 practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage or bodywork 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 of which I am aware. I understand that massage/bodywork practitioners 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/ bodywork 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 practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. I give consent for massage therapy treatment. I understand that the therapy I receive is provided for the basic purpose of clearing meridians, rebalancing the body systems, and for detoxification. Because cupping or the application of oils can be harmful under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I also understand that not all sessions will involve cupping or the use of essential oils. By Signing this I affirm that the massage therapist and Himalayan Salt Therapy, LLC are not liable and that I understand this agreement.

Date: 6/10/2019

Time: 9:39 PM

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