Massage Registration Form

Client Details

Medical Contact Information

Emergency Contact


Please take a moment to carefully read the following information. If you have a specific medical condition, or specific symptoms, massage may be contraindicated. A referral from your primary care provider may be required prior to service being provided.

Have you experiences any of the following conditions?


Is this problem interfering with any of the listed aspects of your life? If so, please explain
The following responses are considered a normal response to relaxation and/or touch which sometimes occurs during a treatment. You need not be embarrassed nor suppress them: Movement or release of intestinal gas – crying – laughing – strong emotions – sighing – groaning – yawning – softening of muscle tissue – cognitive or felt memories – stomach gurgling – the need to move or change position.


I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to a level of comfort. I understand that the massage therapist is not qualified to perform spinal or skeletal adjustments, diagnose or prescribe, or treat any physical or mental illness. I affirm that I have stated all my medical conditions and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so. I acknowledge that the therapist will only work within their scope of practice. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session and I will be liable for payment of the scheduled appointment.
As wonderful as massage is to relax and pamper or perhaps treat yourself to something special, there is also another important factor that people forget. It is also a lifestyle change. The only way we can reap all the benefits of massage is to also make sure that our lifestyles match. Activities in our daily lives such as exercise and diet are just as important as our rest and recreational activities. We must look after all aspect of our lives including our physical, mental, emotional and spiritual growth, in order to find a healthy balance in life.


Greater Relaxation

& Inner Peace