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Bodywork Intake Form
The following information will be used to help plan safe and effective massage sessions. Please answer the questions to the best of your knowledge.

Please read and initial by each of the following statements:

MASSAGE CLIENT INTAKE & CONSENT FORM

Please complete this form before your massage session. The information you provide helps us provide a safe and comfortable experience.

1. CLIENT INFORMATION

Gender:
Birthday
Month
Day
Year

May we send you appointment reminders and promotional E-mail or Text messages?

E-mail
Yes send E-mail
No send E-mail
Text messages
Yes send Text
No send Text

2. ABOUT YOUR MASSAGE TODAY

Session Purpose & Areas to Focus On:
Preferred Massage Pressure:
Daily Routine:

MEDICAL CONDITIONS & RESTRICTIONS (INDICATE IF APPLICABLE)

1. Fever or Contagious Illness. 2. Deep Vein Thrombosis (DVT) Blood Disorders. 3.Recent Surgery (within the past 3 months)
4. Severe Osteoporosis or Acute Bone Fractures. 5. Uncontrolled High Blood Pressure or Heart Conditions. 6.Cancer Treatment / Close Medical Supervision.

Please Note:The establishment reserves the right to decline or modify services for your safety if medical contraindications exist. Consulting a physician prior to massage is advised.

Currently Pregnant
Other Conditions / Allergies (Lotions, Oils, Essential Oils):

SPINE & BONE DISCLOSURE

Do you have any conditions affecting your spine or bones (e.g., spinal conditions, deformities, scoliosis, herniated/compressed discs, spinal fusion surgery, or implanted metal/hardware)?

3. AGREEMENT, ASSUMPTION OF RISK & LIABILITY RELEASE

By signing below, I acknowledge and agree to the following:

1. Accuracy & Medical Disclaimer: Information provided is accurate. I understand massage therapy is for relaxation and muscle relief, not medical treatment, and agree to report any health changes in future visits. 

2. Assumption of Risk & Liability Release: I acknowledge inherent risks (minor soreness, fatigue, bruising) and voluntarily accept them. I release Oriental Massage Wellness, Ltd., its owners, and staff from liability/claims regarding injuries, except in cases of gross negligence. 

3. Client Rights & Professional Boundaries: I may request pressure adjustment or stop the session at any time if I feel uncomfortable. I agree to inform the therapist immediately if I experience any pain or discomfort so that techniques can be adjusted promptly. Services are strictly non-sexual, and draped boundaries will be strictly maintained. Inappropriate or harassing behavior will result in immediate termination of service without refund.

Date
Month
Day
Year

SIGNATURE & ACKNOWLEDGMENT

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CONDITIONS WE DO NOT MASSAGE

(For your safety, please do not receive massage if you have any of the following)

When in doubt, please consult your doctor before your session.

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• Fever or contagious illness

• Blood clots, DVT, or severe blood disorders

• Recent surgery (less than 3 months)

• Severe osteoporosis or acute bone injury

• Heart condition or uncontrolled high blood pressure

• Cancer treatment or currently receiving care

• Pregnancy (unless approved by your doctor)

• Any other condition your doctor advised to avoid massage

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Oriental Massage Wellness © 2023. All Rights Reserved.

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