Short Intake Form

First Name *

Last Name *

Email Address *

Phone Number *

Are you currently experiencing any of the following conditions?

Please list any recent injuries or current medical conditions which may be relevant to your session today:

Please list any areas of pain, concern, or focus for your session today:

Are you currently pregnant or attempting to conceive?

Yes

No

Planning

If pregnant, when are you due?

Do you have a preference for the gender of your therapist? *

No Preference

Female Therapist

Male Therapist

Would it make a difference to you if your therapist were transgendered? *

That would not make a difference.

I would not be comfortable with a trans therapist.

OtherOther

What level of pressure generally works best for you?

1

2

3

4

5

6

7

8

9

10

1=very light, 10=very deep

Please mark any areas which you wish avoided.

I understand that massage therapy involves neither diagnosis nor treatment of any condition, and is not a substitute for medical care. All sessions will consist of only therapeutic massage techniques; draping will be used at all times, and neither my breasts (if applicable) nor genital areas will be massaged. If am uncomfortable for any reason, I may request to end the session, and the session will be ended. *

I agree

I understand the risks of massage therapy, including but not limited to superficial bruising, soreness, and exacerbation of undiscovered injuries, and I release the company and massage therapist of all liability in the case of such injuries. If needed, I have clearance from my physician to receive massage therapy, and I agree to disclose all medical conditions or medications now and in future as changes occur. *

I agree

If you are under the age of 17, you must have written consent of a parent or guardian to receive massage. If you are under the age of 13, a parent or guardian must be present in the massage room for the entire duration of the session. *

I agree

All appointments are at the Triangle location at 4616 Triangle Ave. #407, Austin TX 78751. *

I understand

Cancellations are permitted without penalty up to 12 hours before the scheduled start time. Cancellations within the 12 hour period and no shows will be charged 50% of the non discounted service price. Packages, workshops, and group bookings require 24 hours notice of cancellation. During certain holiday times, all bookings may be subject to a longer cancellation period. I agree to pay all cancellation fees in accordance with Myo policy. *

I agree

My digital signature below certifies my understanding of and agreement with the above policies. *

Clear

Short Intake Form

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