#ThePainKilla

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Online Intake Form

Thank you for choosing MyMassage and Wellness. Please take this time to fill out my secure, online intake form so that I am better prepared at the time of your session. I look forward to meeting you!

Do you have any of the following conditions*
Check all that apply
Are you currently on any medication?*
If you are a female, are you currently pregnant, or is there a possibility that you are pregnant?*
A cancelled or No-Show appointment delays our work. When you must cancel, please give me at least 24 hours notice. I am rarely able to fill a cancelled or No-Show session unless I know at least 24 hours in advance. If you are unable to provide at least 24 hours notice when you cancel, you will be charged a $25 fee for your session.
Please take a moment to read and initial the following information: *I understand that massage therapy is provided for stress reduction, relaxation, relief from muscular tension, and improvement of circulation and energy flow. *If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/strokes can be adjusted to my level of comfort. I will not hold my therapist responsible for any pain or discomfort I experience during or after the session. *I understand that the services offered today are not a substitute for medical care. I understand that my therapist is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness. *I affirm that I have notified my therapist of all known medical conditions and injuries. *I agree to inform the therapist of any changes in my health and medical condition. I understand that there shall be no liability on the therapist’s part should I forget to do so. *I understand that massage is entirely therapeutic and non-sexual in nature. By signing this release, I hereby waive and release my therapist from any and all liability, past, present, and future relating to massage therapy and bodywork.
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