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Balanced Rock Bodyworks

Balanced Rock Bodyworks

stacey@balancedrockbodyworks.com

603-398-5549

  • Home
  • Services
    • Yoga
    • Massage
    • Reiki
  • Paddle Yoga
    • Stand Up Paddleboard
  • About
    • Hours / Contact
    • Forms
  • Blog
  • Events
    • Online Classes
  • Book Now

Client intake form

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Medical

  • Previous History

  • I have completed this form to the best of my knowledge and will inform the massage therapist of any change in my physical health. I understand that a massage therapist can not diagnose illness, disease, or any other medical, physical, or emotional disorder, nor perform any spinal manipulations. I am responsible for consulting a qualified physician for any ailments that I have. If you have a specific medical condition or specific symptoms, massage may be contraindicated. A referral from your primary care physician may be required prior to services being rendered. It is also understood that any illicit or sexually suggestive remarks or advances made will result in immediate termination of the session, and payment will be made for the full scheduled time. I agree to keep the therapist up to date as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should i forget to do so.
  • This field is for validation purposes and should be left unchanged.

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