404.556.6363
The following form is meant to Better Serve Your Needs and Deliver the Highest Level of Proficiency with Each Massage!
Sweet Earth Therapeutic Massage, LLC
Myrna Lovell-Jones, LMT, CMT, NMT
125 E Trinity Pl, #306 Decatur Georgia 30030
CLIENT INTAKE FORM
Full Name: ___________________________________________________ DOB: ____________________
Address: __________________________________________________________
City: ______________________________ State: ______ Zip: __________
Phone #: _______________________ Email: _________________________________________________
Occupation: ________________________ Emergency Contact: ____________________________________
Phone #: ____________________ Relationship: ________________________________________________
Physician: __________________________________ Phone #: __________________________
Medical History Health Conditions: ____________________________________________________________
Please indicate any of the following conditions that you currently have:
□ Headaches □ Allergies □ Arthritis, Tendinitis □ Cancer □ TMJ □ Abnormal Skin Condition □ Epilepsy or Seizures
□ Heart/Circulation Problems □ Joint Surgery □ High/Low Blood Pressure □ Major Recent Accident □ Diabetes
□ Varicose Veins □ Blood Clots □ Neck/Back Injuries □ Fibromyalgia □ Numbness □ Sprains, Strains □ Bruise Easily
□ Recent Injuries □ Wear a Pacemaker □ Had Surgery Performed within the last 30-days □ Take Blood Thinners
□ Osteoporosis □ Allergic to Latex □ Accident/Broken Bones in the past 2-Years □ Pregnant
Explain Any Conditions Not Shown Above: __________________________________________________________
I hereby request and consent to massage therapy and have been informed about the type of massage/modality of treatment, and which body areas will be worked on.
I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during the session, I will immediately inform the therapist so that the pressure, strokes and/or stretches may be adjusted to my level of comfort. I further understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the massage therapist updated as to any changes in my medical profile during the session and understand that there shall be no liability on the massage therapist; namely, Myrna Lovell-Jones’ part, should I fail to do so. I understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session. I also understand that the License Massage Therapist reserves the right to refuse to perform massage on anyone whom she deems to have a disqualifying condition.
Clients Signature: __________________________________________
Date: _______________
Date: _______________Printed Name:
