Fairfax Station Chiropractic

Massage Therapy Intake Form

Please complete all sections thoroughly and accurately

All information will be kept strictly confidential

Include year and treatment received
I,
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Acknowledge that this medical information is accurate and true to the best of my knowledge. If I experience any pain or discomfort during the massage, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I agree to communicate with my therapist any time I feel like my well-being is compromised. I understand that massage therapy is not a substitute for medical examination, diagnosis, or treatment. I understand that a massage therapist cannot diagnose illness, disease, or any other medical, mental, or emotional disorder. Massage therapists are not qualified to perform skeletal adjustments, prescribe, or treat any physical or mental illness. I take responsibility for alerting my therapist to any changes that occur with my health and understand that there shall be no liability on the therapist's part should I fail to do so.

Cancellation policy text

A 24-hour notice MUST BE GIVEN for all canceled appointments to avoid a charge. If less than 24 hours notice is given, the client will be responsible for half the cost of the massage. Clients who do not show up for their massage appointments and do not call before their scheduled massage start time will be responsible for the full price of the massage.

Please arrive ON TIME for the massage appointment. In the event that you arrive after your scheduled start time, the appointment's end time will remain the same. As a courtesy to the other clients, the massage therapists must adhere to the original agreed upon length of the massage. Continuing the massage past the scheduled end time is solely at the discretion of the massage therapist. The length of the scheduled massage appointment includes the massage itself, as well as the initial consultation and time for changing. Your first visit involves initial paperwork, which will be part of your appointment time if you do not arrive early.

By submitting this form, you acknowledge that all information provided is accurate and complete.

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For questions about this form, please contact our office.