Balanced Body Massage Intake Form

Massage Therapy Intake Form

Complete Intake Form prior to your scheduled appointment.
Full name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number*

Area CodePhone Number
Cell Phone Number*

Area CodePhone Number
E-mail*
Emergency Contact*

First NameLast Name
Emergency Contact Phone number*

Area CodePhone Number
Massage Therapy Intake

Complete Health and Wellness Intake Form. Attest and Initial Agreement.
Birth Date*

MonthDayYear
Gender / Male or Female*
Weight *
Table setup adjustments
Height*
Table setup adjustments
Were you referred by a Medical Professional or a client? Do you have an accute injury? Need emergency care? How did you hear about us? Please be specific. *
Are you in any pain or discomfort? Please describe your pain, discomfort or area of concern and how it affects you or prevents you from normal daily activities. Please be detailed.*
Detail description of pain or discomfort
If you are in pain or discomfort, have you seen a Medical Specialist?*
Have you had a Medical Physical in the past 12 months?*
Has your Medical Doctor recommended against receiving Massage Therapy or do you suffer from any conditions that may prevent you from safely receiving Massage Therapy Treatment.*
Have you had a Professional Massage Therapy Treatment before?*
What are your goals for Massage Therapy Treatment?*
What type of Massage Therapy Treatment do you prefer?*
Do you suffer from Bone Disease or Joint Disease, including Arthritis? *
Do you have Joint Replacements, Corrective or Medical Implants*
Do you have Heart Conditions, High or Low Blood Pressure or Diabetes?*
Do you have any Vascular issues?*
Do you have any Medical Conditions, Allergies, or Musculoskeletal Pain?*
Are you currently taking Prescription Drugs or over the counter drugs?*
Do you have recent injuries, surgeries, open wounds or skin disorders.*
Do you have injuries or conditions that require special considerations?*
Do you suffer from any conditions that may cause hypersensitivity or a lack of sensitivity to heat or cold?*
Do you prefer heat or cool on the Massage Table.*
Do you require any special care or bolstering?*
I attest to the accuracy of the intake information submitted*

Clear
Balanced Body Studio Policy Agreement/Please Initial Agreement.
Balanced Body Massage Policies
Consent, Safety Protocol and Acknowledgement Waiver:
Balanced Body Massage will take all precautions in ensure the safety and well-being of the client during Massage Therapy and/or Fitness and Wellness Sessions under the NYS Protocol and the National Exercise and Sports Trainers Association. We recommend you receive Medical Clearance for your safety.

Medical Consent:

The client states they are fit for an Exercise Program/ Massage Therapy Treatment and has received Medical Clearance for Fitness Training and/or Massage Therapy Sessions and /or understands the risk of injury involved with increasing physical activity and/or receiving treatments without the consent of a physician and has decided to go forward with a Fitness Program and or Massage Therapy Program. The client further understands and consents to assessments, program design, and/ or treatments by the Therapist/ Trainer. The Therapist/ Trainer recommends Medical Clearance by a Physician before starting Therapy and/or Fitness Sessions.

Acknowledgment Waiver :

The client is hereby requesting a Consultation and/or Services with Balanced Body Fitness and Wellness LLC, Pilates Fitness & Wellness, Balanced Body Massages, and /or Myokinesis Therapy and Daniel Thomas for the sole purpose of potentially retaining a Therapist or Personal Fitness Trainer and for no other reason. I acknowledge that I am not an agent or employee of any local, state, or federal government authority; or if I am employed as an agent or employer of any local, state, or federal government authority that I am seeking this consultation in my capacity and not the capacity as government agent or employee. If consultation is on behalf of a business entity and not an individual I further represent that I am either a principal, managing agent, or partner, or if a partner, or an agent, I am authorized to execute authorization and waiver on behalf of my principle.

I acknowledge that permission for me to enter the premises or any premises related to the ownership or business of Balanced Body Fitness and Wellness LLC, and/or to receive consultation and/ or services is based on the above acknowledgment, and any misrepresentation made herein to receive the consultation and/or services will be deemed entrapment and Trespassing with Malicious Intent, intentional infliction of emotional distress and all other applicable damages.

I waive any defenses I may have against me for entrapment, Trespassing with Malicious intent, Trespassing, Trespassing to Chattel, harassment, fraud in the inducement, intentional infliction of emotional distress, and any other damages incurred by Balanced Body Fitness and Wellness LLC and/or Daniel Thomas as a result of misrepresentation stated above for receiving consultation and/or services rendered to me.

I am aware that signing this document under pretenses is a crime punishable under the laws of New York State.

I have read this document, understand its contents, and sign this waiver of my own will.

Safety Protocol and Waiver:

I read and understood Balanced Body Fitness and Wellness Safety Protocol and Policies as noted in detail on our Safety Protocol Web Page.

Your safety is our priority and we strongly recommend medical clearance from a Medical Doctor before using our services. If you feel medical clearance is unnecessary and decide to go forward with our services, you must follow our strict safety protocols. You also understand and acknowledge that our protocols are designed to minimize risk of injury.
Medical Consent, Safety Protocol and Acknowledgement Wavier Agreement *

Clear
Balanced Body Studio Policy Agreement / Please Initial Agreement.
Cancellation Policy
At Balanced Body Massage, all appointments are binding. All sessions are prepaid. Rescheduling requests must be received at least 24h before your session in order to avoid being charged. Clients who do not request a rescheduling appointment within 24h notice will be charged 100% of the regular price of your session.
Cancelation Policy Agreement*

Clear
Balanced Body Studio Policy Agreement / Please Initial Agreement.
Massage Treatment Policy
Please complete the intake form with detailed description of your concerns. A MD clearance is generally recommended, however if you prefer, our in house Nurse Practitioner can evaluate your Intake Information and forward any recommendations. Once we have evaluated your intake information, our specialist will schedule an appointment. When you arrive for your appointment, our Therapist will screen you and complete a physical assessment, discuss appropriate treatment and continue with your treatment. I understand the Policies set forth and authorize treatment and understand risks involved. We implement safety protocols and require all patients to follow those safety guidelines. Safety Guidelines are detailed on our "Safety Protocol Page" of our website.*
Please note any concerns or questions regarding Massage Therapy Treatments. If you have no concerns please note NONE.
Electronic Signature. I read and agree to Balanced Body Massage Therapy Policies, Safety Protocol Agreement and Authorize Treatment. *

Clear
Balanced Body Studio Policy Agreement / Please Initial Agreement.
NYS PICTURE ID / DRIVERS LICENSE (submit with Intake Form)*

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DOWN LOAD NYS PICTURE ID/DRIVERS LICENSE or Send copy of NYS PICTURE ID/ DRIVERS LICENSE via Text to 631.318.4696 Cancelof
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MonthDayYear
Should be Empty:

Massage Therapy Intake Form

Massage Therapy Intake

Balanced Body Massage Policies

Consent, Safety Protocol and Acknowledgement Waiver:

Cancellation Policy

Massage Treatment Policy