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Ambiance Massage Therapy LLC Client Intake Form

Name______________________________ Home Phone___________________________

E-mai_____________________________ DOB_________________ Address_____________________

City_____________________ St______ Zip_______________________


Exercise/Activitity / How often____________________________________Occupation____________________________

Primary Care Physician______________________________

Medications________________________________________May Therapist contact physician above if necessary? YES NO

Have you ever had a massage?_____________ If so, what type and how often____________________________

What are your goals/ expectations of this therapysession?____________________________________________

Do you have / had any of the following conditions? If yes to any of the following please explain clearly.
____Stress ____Allergies ____Contagious Disease ____Spasms/ Cramps ____Arthritis ____Joint swelling ____Osteoporosis ____Sensitive to touch ____HIV ____Bruise easily ____Varicose Veins ____Skin Problems ____Cancer ____Blood Clots ____Epilepsy/ Seizures ____Circulatory problems ____Fever ____Sleep Problems ____Headaches ____Surgeries or Accidents ____Pregnant ____Numbness ____Neck/ Shoulder Pain ____ Depression/Panic disorder

Extra Comments:____________________________________________________________________________________________ __________________________________________________________________________________________________________

Are you allergic to Nut products? ___Y ___N

Are there any areas you DO NOT wish to be massaged (Breast and Genitals are NEVER massaged)_______

Massage Therapists Notes:

During Your Massage The following are normal responses to relaxation and or/ touch which sometimes occur during massage.
You need not be embarrassed nor suppress them crying-laughing-strong emotions-sighing-groaning-yawning-softening of muscles-stomach gurgling-cognitive felt memories-the need to change positions- falling asleep.

After your massage Its normal to feel a little sore and light headed after your massage. Recommendations are : Drink water..If you dont drink enough water you may feel tired and achy 0-4 bottles of water is ideal.

A soothing bath..a good way to let the body unwind is a relaxing bath with Epsom Salts ( 2 cups) per bath.

Therapeutic Breast massage will NOT be performed. Draping will be used during the entire session , client will remain covered at all times, only area being worked will be exposed. Clients under the age of 17 must have a signed consent from parent / guardian with a phone number for verification.

Agreement: I understand that massage therapy can be very therapeutic, relaxing, and reduce muscular tension, it is not a substitute for medical examination, diagnosis or treatment. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments prescribe or treat any physical or mental illness and that nothing said in the course of the session should be construed as such, and that I should see a physician, chiropractor or qualified medical specialist for any mental or physical ailment that I am aware of. Because massage is not performed under certain medical conditions, I affirm that I have stated all my known medical condition and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist 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 also understand that all payments are due in-full at the time services are rendered. If for any reason I need to cancel an appointment I will do so within 24 hrs, failure to comply will result in paying appointment fees, which will be the cost of the massage in which you had scheduled. I have read and understand this form in its entirety.

_________________________________________ _________________________________________
Signature of Client Date

_________________________________________ _________________________________________
Signature of Therapist Date