HEALING MOTIONS
LLC

Sport Massage Intake Form

First name

Last name

Phone (pick country)

Birthday

Month

Day

Year

Service Address

Multi-line address

Country/Region

Address

City

Zip / Postal code

Any medical History or Surgeries?

Are you currently taking any medications

Yes

Please list medications being used.

Do you have any allergies?

Yes

Please list any Allergies

Are you Pregnant?

Yes

Have you had a massage before?

Yes

What type of Sports Massage are you interested in getting?

Pre-event Massage: 2-3 days before the event. Deeper tension relief. Allow 24-48 hour recovery to ensure you are ready for your event. (if you are naturally more tender, book 4 days before.)

Post event Massage within 24 hours: Gentle/light circulatory massage and stretching to assist with recovery

Post event massage 24-72 hours post event: The goal is to address DOMS. Focus on Deep tissue, Trigger point therapy, increasing circulation, and mobility.

Maintenance : Often done Bi-weekly or monthly between intense training periods. Helps prevent build up of chronic tension, promotes flexibility, and range of motion.

Rehabilitative: Post injury often requires a Dr. Note. Goal is to increase circulation around an injury to help the healing process. Will not work on acute injuries without medical release.

If you are under 18, adult consent is needed.

Check Here if you are filling out this form for a minor under the age of 18

Name of Parent/ Guardian

Age of Minor

As the parent or guardian of this minor, you understand this this is a sports massage. A parent or guardian must be present during the session. This session may include combinations of Circulatory Massage, Deep Tissue Massage, Stretching, tissue manipulation, another massage techniques including friction and trigger point therapy. By checking this box you are giving permission for Healing Motions LLC to work on your minor.

Acknowledgments

I understand that My Massage Therapist does not recommend any intense activity within 24 hours post massage.

I understand that Massage therapy is provided for stress reduction, relaxation, relief from muscular tension, and improvement of circulation & energy flow.

If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/ strokes can be adjusted to my level of comfort. I will not hold my Therapist responsible for any pain or discomfort I experience during or after the session

I understand that services provided are not suitable for medical care and that my therapist is not qualified to diagnos, prescribe, or treat physical/mental ilness.

I affirm that I have notified my Therapist of all known medical conditions

I agree to inform my therapist on any changes in my health and medical condition and that there should be no liability on the Therapists part should I forget to do so.

I understand that massage is entirely Therapeutic and non-sexual in nature

I understand that my massage Therapist has the right to refuse service to anyone, for any reason, at any time.

By signing this release, I waive and release my therapist from any liability, past, resent, and future, relating to massage therapy and body work.

Signature

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HEALING MOTIONS LLC

Sport Massage Intake Form

HEALING MOTIONS
LLC