Colacurcio Wellness - Caldwell NJ 973-228-2481

Massage Therapy Intake Form


Name:  
Cell or Primary Phone:  
Email:  
Address:  
DOB:  
Emergency Contact:  
Phone:  

 

If you have a specific medical condition or specific symptoms, massage/bodywork may be contraindicated. A referral from your primary care provider may be required prior to service being provided.
(Check all that apply)

If you answer YES to any of the above questions, please explain as clearly as possible:
 

What are your goals for today’s treatment?
What kind of pressure do you prefer?  

I understand that the massage/bodywork treatment I receive is provided  for the basic purpose of relaxation of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the treatment, pressure, and/or strokes may be adjusted to my level of comfort. I further understand that massage or bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage/bodywork should not be performed under certain medical conditions I affirm that i have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner's part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.

Consent to Treatment of Minor: By my signature below, I hereby authorize Colacurcio Wellness LLC. to administer massage, bodywork, or somatic therapy techniques to my child or dependent as they deem necessary.

Leave this empty:

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Signature Certificate
Document name: Massage Therapy Intake Form
lock iconUnique Document ID: 1911e38871c7b803eeebb6a6644f94ff7441ce4a
Timestamp Audit
June 30, 2022 7:57 am ESTMassage Therapy Intake Form Uploaded by Steve Colacurcio - scolacurcio@icloud.com IP 173.70.19.34