Minor Consent Form

Massage Therapy Intake Form

Do you have any of the following conditions?*
Please select at least one option
Are you currently under a physician's care for any of the above conditions

Privacy Policy: Due to HIPAA Privacy Regulations, our office is required to offer you a notice of our privacy practices. This document lets you know what steps we take in protecting your health information. Please ask the front office staff if you would like a copy.

Cancellation Policy


To avoid being charged a $45 cancellation fee, I agree to give 24 hours notice.

Massage Consent

I have been advised of the policies and procedures pertaining to massage and I understand these policies. The massage procedures, information about massage in general, benefits and contraindications of massage, and possible alternative therapies have been explained to me.

I understand that the massage I receive is for the purpose of stress reduction and relief of muscular tension, spasm, or pain, and to increase circulation. If I experience any pain or discomfort, I will immediately inform the therapist so that the pressure or methods used can be adjusted to my comfort level. I understand that massage therapists do not diagnose illness or disease, nor do they perform spinal manipulations or prescribe any medical treatments, and nothing said or done during the session should be construed as such. I acknowledge that massage is not a substitute for medical examination or diagnosis, and I should see a health care provider for those services. Because massage should not be performed under some circumstances, I agree to keep the massage therapist updated as to any changes in my health, and I release the massage therapist and Holistic Health Clinic from any liability if I fail to do so.

Thank you for taking the time to fill out this form.

Office Hours

Monday

10:00 am - 7:00 pm

Tuesday

10:00 am - 7:00 pm

Wednesday

10:00 am - 7:00 pm

Thursday

10:00 am - 7:00 pm

Friday

10:00 am - 7:00 pm

Saturday

10:00 am - 5:00 pm

Sunday

10:00 am - 5:00 pm

Monday
10:00 am - 7:00 pm
Tuesday
10:00 am - 7:00 pm
Wednesday
10:00 am - 7:00 pm
Thursday
10:00 am - 7:00 pm
Friday
10:00 am - 7:00 pm
Saturday
10:00 am - 5:00 pm
Sunday
10:00 am - 5:00 pm

Location

New Patient Inquiry