Confidential Health Intake Form

To comply with informed consent I will discuss the following with you prior to your treatment:
1. What to expect from your entire treatment
2. Proposed treatment plan and goal
3. Any contraindications or precautions for massage
Please take a moment to carefully read the following information and sign where indicated.
I understand that the massage/bodywork I receive at ReAwake is provided for basic purpose of relaxation and relief of muscular tension.
If I experience any pain or discomfort during this session I will immediately inform the practitioner so that the pressure and or/ strokes may be adjusted to my level of comfort.
I further understand that massage/bodywork should not be construed as a substitute for an examination, diagnosis or treatment of disease/injuries.
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 should be no liability on the practitioner’s part should I forget to do so.
I also understand that any illicit or sexually suggestive remarks or advances will result in termination of the session, and I will be responsible for payment of the scheduled session.
I agree and adhere to ReAwake’s cancellation policy and will be responsible for charges if I fail to provide 24 hour notice if I cancel or change my appointment.
The parties agree that this document may be electronically signed. Electronic signatures appearing on this agreement are the same as handwritten signatures for the purpose of validity, enforceability, and admissibility.