Intake & Health Information

PLEASE READ THE FOLLOWING INFORMATION CAREFULLY, SIGN AND DATE.

Note: excepting emergency or illness, if your appointment must be changed with less than 24 hour notice, you will receive a extra, complimentary ½ hour on the rescheduled appointment.

I agree to treatment with massage therapy for my condition. I understand that massage is not a substitute for medical examination, diagnosis, or treatment and that I should consult a physician, chiropractor, or other medical specialist for any mental or physical ailment of which I am aware. I also understand that massage therapists are not qualified to perform spinal or skeletal adjustments, to diagnose, or to prescribe medication, and that nothing said in the course of the session should be construed as such. Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly; therefore, the massage therapist is not responsible for the aggravation of any conditions which are present but not disclosed to her prior o the massage therapy treatment. I agree to update the therapist about any changes in my medical condition, and I understand that there will be no liability to the therapist should I neglect to do so. If I experience any pain or discomfort during the session, I will immediately inform the therapist so that she can adjust the treatment. Finally, I understand that I am solely responsible for payment of my treatments, and that payment is due at the time of service unless arranged otherwise prior to the session. Our time together is precious, and I agree to cancel 24 hours in advance unless there is an emergency or illness.

Excluding the previously mentioned cases, if I miss an appointment without notice, I agree to pay ½ the

appointment fee.