Andrea Zamora

INTAKE & CONSENT FORMS

Filling out these forms electronically before we meet is incredibly helpful - it lets me get to know you in advance and reduces paper waste. Copies are available in office as well if you aren't able to get to it in time. Thank you!

CLIENT INFORMATION

First name

Last name

Birthday

Month

Day

Year

Phone

Emergency Contact Name

Emergency Contact Phone Number

Multi-line address

Country/Region

Address

City

Zip / Postal code

HEALTH INFORMATION

Are you taking any medications?

Yes

If yes, please list:

Any allergies? (oils, lotions, nuts, fruits, skin, etc.). If yes, please list:

Are you pregnant?

Yes

If yes, how many months? Due date?

Are you currently under medical supervision or receiving other medical interventions?

Yes

If yes, please describe:

Areas of broken skin? (e.g. rash, wounds, etc.)

Yes

If yes, where?

History of joint replacement surgery?

Yes

If yes, which joints?

Recent medical procedures or injuries in the past 2 years?

Yes

If yes, please describe:

Please describe any other injuries or health conditions:

MASSAGE INFORMATION

Have you had a professional massage before?

Yes

If yes, how recently?

Reason for seeking massage?

How much pressure do you prefer?

Light

Medium

Firm

Are there any specific parts of your body that have discomfort?

I understand that the massage I receive is provided for the basic purpose of relaxation, stress reduction, and relief or muscular tension. I further understand that the massage 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 mental or physical ailment that I am aware of.
I understand that massage therapists are not qualified to perform skeletal adjustments, diagnose and/or prescribe, and that nothing said in the course of the session should be construed as such.
Because massage is contraindicated under certain conditions, I affirm that I have stated all my known medical conditions 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's part should I forget to do so.
By clicking "Submit" below, I acknowledge that I om aware of the benefits and risks of massage therapy and that I have completed this form to the best of my knowledge. I also agree to inform my massage therapist of any health or medical changes.

Date

Month

Day

Year