Massage Therapy Intake Form

Personal Information

Birthday

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Health History

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Consent

By signing this consent form, I understand that Eileen Bild does not diagnose illness, disease or any other medical disorder. Eileen Bild does not provide medical treatment or pharmaceuticals. I understand that any services provided are not a substitution for medical treatment and that I should see a physician for any physical ailment that I might have. I understand that the massage I receive is provided for the purpose of relaxation and/or relief of muscular tension. If I experience any discomfort during the session, I will immediately inform the therapist so that the pressure and strokes may be adjusted. Because practitioners must be aware of any existing physical conditions, I have stated all my known medical conditions. Therefore, I assume all risk for my health and hold harmless Eileen Bild and any associated business entities, practitioners, Amenities or persons involved in services performed. I also understand that the License Massage Therapist reserves the right to refuse or terminate the massage session to anyone whom she considers to have a condition for which massage is contraindicated.

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