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Massage Intake


Personal Information


(Optional) Contactless Scheduling & Checkout Procedures: When scheduling your appointment online, you have the option to enter your credit card for contactless checkout option. To be kept securely on file. This credit card will be used for all future appointments until otherwise notified.

Massage Intake




Medical History










I, , have informed the massage therapist of all my known physical conditions, medical conditions and medications, and I will keep the massage therapist updated on any changes. I understand that there shall be no liability on the therapist’s part should I forget to do so. I have carefully read all the above information and am fully aware of what I am signing. I understand that I may ask the massage therapist for additional information before signing this consent form. I give my permission and consent to massage therapy.

If under age of 18, guardian signature is required.

September 30, 2020

Massage Bodywork Consent and Privacy Policy

Massage Therapy: I understand that massage therapy and bodywork is intended to enhance relaxation, reduce stress, increase range of motion, and offer relief from muscular tension, spasm or pain. I also understand that it may increase circulation and energy and blood flow. If I experience any pain or discomfort during this session, I will immediately inform the massage therapist so that the pressure may be adjusted to my comfort level. I have been notified that, for therapeutic benefit, discomfort may be present and will be discussed and agreed upon by, both myself, and the massage therapist. The general benefits of massage therapy, possible contraindications, and the treatment procedure have been explained to me. I understand that massage therapy is not a substitute for medical treatment or medications, and that it is recommended that I concurrently work with my Primary Caregiver for any condition that I may have. I am aware that the massage therapist does not diagnose illness or disease, does not prescribe medications, and that spinal manipulations are not part of massage therapy.

Accessory Techniques: I understand that I may also be given acupressure and/or Tui-Na massage as part of my treatment to modify or prevent pain perception and to normalize the body’s physiological functions. I am aware that certain adverse side effects may result. They could include, but are not limited to: bruising, sore muscles or aches, pain or discomfort, and the possible aggravation of the symptoms existing prior to treatment. I understand that Gua Sha and Cupping therapy are for the purpose of relief from muscular tension or spasm and for increasing circulation and energy flow. I understand that Gua Sha & Cupping therapy may cause side effects like bruising, discomfort or skin bleeding. Forward Movement & Massage, LLC has informed me of these things and I understand their meaning and may refuse treatment.

Privacy Policy: The information received and collected from my visit is strictly private and confidential. It is used and viewed only by the healthcare professionals associated with Forward Movement & Massage, LLC, unless, in my best interest, a practitioner determines that there is a need to communicate with another person or healthcare professional outside of Forward Movement & Massage, LLC. Forward Movement & Massage, LLC will not give, share or transfer any personal information to a third-party unless required by law. Under absolutely no circumstances will this communication happen without my signed consent. Please notify us if you would like to receive a copy of our privacy Policy.

Pricing & Fees: Standard rates vary from $60-$75/hr and $90-$100/90-min session, depending on location. Cancellations within 24 hours may be subject to paying full session fee. Returned checks are subject to a $25 fee.

I have received a copy of FORWARD Movement & Massage LLC’s Consent & Privacy Policy. I have read all policies and I understand them. The procedures of the massage, general information about massage and massage benefits, as well as specifics of the therapy, have been explained to me. I also understand that the therapist and I have the right to refuse or terminate the massage session at any time.

If under age of 18, guardian signature is required.

September 30, 2020