theactivemassage@gmail.comMon-Fri: 8am-7pm, Sat: 8am-12pm, Closed Thur
Michael Read Massage Michael Read Massage
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Patient Intake Form

Michael Read Massage > Patient Intake Form

Personal Information

Name
Address
MM slash DD slash YYYY

Medical Information

Are you taking any medications
Are you currently pregnant?
Do you suffer from chronic pain?
Have you had any orthopedic surgeries?
Please indicate any of the following that apply to you.

Massage Information

Have you had a professional massage before?
What type of massage are you seeking?

What pressure do you prefer?
Do you have any allergies or sensitivities?
Are there any areas (feet, face, abdomen, etc.) you do not want massaged?
I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time.(Required)
I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time.

General Liability Release Form

By signing below, you agree to the following:

  • I consent to receive massage therapy.
  • I understand it is not a substitute for medical treatment or medications.
  • The therapist does not diagnose conditions or prescribe medications.
  • I have physician clearance for massage therapy.
  • I acknowledge possible risks, including:
    • Superficial bruising
    • Muscle soreness
    • Worsening of undiscovered injury
    I release the company and therapist from liability for these risks.
  • I will inform the therapist of any medical conditions, medications, or discomfort during the session.
  • Either party may end the session at any time.
  • I have had the opportunity to ask questions.

By signing below, I acknowledge and agree to these terms.

Clear Signature
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Location
168 Main Street
2nd Floor
Huntington NY, 11743

Opening Hours:
Monday-Friday: 8am – 7pm
Saturday: 8am – 12pm
Thursday: Closed
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Give us a call or drop by anytime, we endeavour to answer all enquiries within 24 hours on business days.

theactivemassage@gmail.com