Intake Form

Confidential Health Form

I hereby request and consent to the performance of massage treatments by a Licensed Massage Therapist from Mass Mobile Massage.

I understand that methods of treatment may include, but are not limited to, Swedish massage, Deep tissue massage, trigger point therapy, Myofascial release techniques, Thai massage, Stress reduction techniques, injury rehabilitation techniques, pre-natal and post-natal techniques, Electro-acupuncture, TENS, energetic work, body awareness work, postural techniques, hot stone Massage, reflexology, sports massage techniques, facilitated stretching techniques, medical Massage and emotional balancing.

I will notify the Massage Therapist if I am or become pregnant or have any blood diseases, injuries or other health risks that could possibly be contraindicated for massage or other bodywork.

I do not expect the Massage Therapist to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely on the Massage Therapist to exercise judgment during the course of treatment which the Massage Therapist thinks at the time, based upon the facts then known is in my best interest. I understand that results are not guaranteed. I also understand that long term pain reduction takes more than one treatment. I understand the Mass Mobile Massage staff may review my patient records, but all my records will be kept confidential and will not be released without my written consent.

I, the undersigned, hereby expressly and affirmatively state that I wish to participate in massage.  I realize that my participation in this activity involves risks of injury including but not limited to: cardiovascular and orthopedic type injuries, serious disabling injuries, and even the possibility of death. I also recognize that there are many other risks of injury that may arise due to my participation in this activity, and that it is not possible to specifically list each and every individual injury risk. However, knowing the material risks and appreciating, understanding, and anticipating that other injuries and even death are a possibility, I hereby expressly assume all of the delineated risks which could occur by reason of my participation. I have had an opportunity to ask questions.

Any questions I have asked have been answered to my complete satisfaction. I subjectively understand the risks of my participation in this activity, and I voluntarily choose to participate, assuming all risks due to my participation.

Gratuity is not included and if satisfied with the treatment I will consider providing gratuity.

I understand that a cleansing shower before the massage will add to the enjoyment of the treatment. I understand that there are no refunds at anytime once the purchase is made.

Personal Information
Massage Information
  2. Areas of your body that you hold tension or stress
  5. What activities/therapies have you found helpful for your lifestyle?
  9. What results do you want from your treatments?
 

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By clicking submit, I attest that all the information provided is true and accurate. I have read, or have had read to me, the above consent to treatment and I consent to massage treatment. This consent form covers additional massage treatments unless you have notified us of any changes in medical conditions or medications. I am responsible for notifying Mass Mobile of any such changes prior to additional treatments.