Client Intake Form

Client Intake Form & Health Release Form

Personal Information

Massage Experience

Have you had a professional massage before? Yes No

Current Health

Do you exercise regularly and/or participate in any sports? Y N

Do you perform any repetitive movement in your work, sports or hobby? Y N

Do you sit for long hours at a workstation, computer or driving? Y N

Do you experience stress in your work, family, or other aspect of your life? Y N

Are you experiencing tension, stiffness, discomfort or pain? Y N

Have you recently had an injury, surgery, or areas of inflammation? Y N

Do you have sensitive skin? Y N

Do you have any allergies to oils, lotions or ointments? Y N

Health History

Client Agreement

It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status. I understand that the american massage therapy association® has provided this form as a reference and is not held liable for any services provided.

Insurance Information

Is your condition the result of an auto accident? Yes No

A work injury? A health condition? Other

What type of insurance do you have that may cover you for this condition? (check all that apply)
Auto Workers' compensation/state Industrial Liability Health

Was a police/accident report filed? Yes No

Client's relation to insured? Self Spouse Partner Child Other

Male Female Single Married Partnered Other

Secondary Insurance Information

Has an attorney been retained? Yes No

Assignment of Benefits

I am responsible for all charges for all service provided. In the unfortunate event that my insurance company denies payment, or makes a partial payment, I am responsible for any balance due. If you, my massage therapist, have contracted with my insurance company at a discount rate for services, the amount remaining will be waived and I will not be asked to pay the balance. I authorize and direct payment of medical benefits to my massage therapist, for services billed.

Release of Medical Records

I authorize the release of medical records or other health care information, including intake forms, chart notes, reports, correspondence, billing statements, and other written information to my attorneys, healthcare providers, and insurance case managers, for the purposes of processing my claims.

(Please inform your practitioner immediately upon signing any exclusive Release of Medical Records with your attorney that may impact the above release statement.)

Contract for Care

I will participate fully as a member of my healthcare team. I will make sound choices regarding my sessions' plan based upon the information provided by my massage therapist. I agree to participate in my own self-care programs and adhere to the plan we select. I agree to communicate with my practitioner any time I feel my well-being is being compromised. I expect my practitioner to provide safe and effective treatment to the best of his or her skills and knowledge.

This form was created as a resource by the american massage therapy association® and they are not held liable for any services provided.