Massage Therapy

Service Date*

Name*

First Last

Date of Birth*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Medical History

1. Are you currently under the care of a Physician?*

Yes
No

If yes, for what?

2. Are you taking any medications?*

Yes
No

If yes, please list medication and what its for (Example: Albuterol - Asthma)

3. Are you pregnant?*

Yes
No

If yes, how far along? Risk factor (low, med, or high)?

4. Are you on birth control or hormone replacement therapy?*

Yes
No

If yes, please list name?

5. Have you ever had an allergic reaction to cosmetics, food, drugs, or flowers?*

Yes
No

If yes, please explain?

6. Please check any of the following conditions that you have*

If yes, please explain?

6. Do you suffer from chronic pain*

Yes
No

If yes, please explain

What makes it worse/better?

7. Have you had any orthopedic injuries?*

Yes
No

If yes, please list

1. Have you had a professional massage before?*

Yes
No

2. What type of massage therapy are you wanting today?*

Relaxation
Therapeutic (Deep Tissue, Sports, etc)
Combination

3. What type of pressure do you prefer?*

Light
Medium
Deep

4. Are there any areas (feet, face, abdomen, etc.) you do not want massaged?*

Yes
No

If yes, please explain.

5. What is your goal for the treatment session today?

Policy & Consent

At Synergy Skin care & Spa, it is our intention to provide our guests with professional and therapeutic services in a relaxing and friendly environment; we will tailor each treatment to our client’s individual needs. If you experience any pain or discomfort during the session, you will immediately inform the therapist so that the pressure and/or strokes may be adjusted to your level of comfort. I further understand that services provided are NOT a substitution for a medical examination, diagnosis or treatment by a medical or chiropractic physician or other healthcare specialist.

Informed Consent*

I understand that I will be receiving massage therapy for the purpose of stress reduction, relief from muscle tension or spasm, or for increasing circulation and energy flow.
I understand that the massage therapist does not diagnose illness, and as such, the massage therapist does not prescribe medical treatment or pharmaceuticals, nor do they perform any spinal manipulations.
I am aware that this massage is not a substitute for medical examination/diagnosis and that it is recommended that I see a physician for any ailment that I might have.
I understand and agree that I am receiving massage therapy entirely at my own risk. In the event that I become injured either direction or indirectly as a result, in whole or in part, of the aforesaid massage therapy, I HEREBY HOLD HARMLESS AND INDEMNIFY the therapist, their principals, and agents from all claims and liability whatsoever.

Photography Policy*

I give permission for photographs to be used by Synergy Skin Care & Spa for educational and/or promotional purposes. Complete client confidentiality will be maintained at all times.

I agree to the photography policy.
I do not agree to the photography policy.

Name*

First Last

I have read and fully understand the terms within the above policies and consent. All my questions have been addressed to my satisfaction. I certify that all of the above information is true and to the best of my knowledge. I understand and agree with the policies. By signing this form, I waive any and all claims, damages, action and liabilities against Synergy Skin Care & Spa arising out of or relating to massage therapy, hand/foot treatments, skincare and allergic reactions to services performed. In the event a dispute arises over the outcome of my procedure, I consent solely to arbitration as a legal means of settlement. I understand English, or if I do not, I have appointed someone to translate this consent form in its entirety. I am eighteen years of age (18) or older.

Date*

Name

This field is for validation purposes and should be left unchanged.

Massage Treatment

Massage Intake Form

Medical History

Massage Therapy

Policy & Consent