Intake Form

Please take a moment to fill out our intake form. Be sure to let us know anything you feel is pertinent to your treatment.

First name

Last name

Phone (please include a 1 before the area code)

Address

Yes, subscribe me to your newsletter.

Do you have any allergies? (oils, lotions, nuts, fruits, skin, etc)

Yes

If yes, please list

Describe injuries, concerns, or issues you would like to address

Have you recieved treatment for these issues in the past? If so, please explain.

Describe your treatment goals

Please read and sign:

I understand that massage therapy is provided for stress reduction, relaxation, relief from muscular tension, and improvement of circulation and 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 before, during, or after the session.
I understand that today's services are not a substitute for medical care and that my therapist is not qualified to diagnose, prescribe, or treat physical/mental illness.
I affirm that I have notified my therapist of all known medical conditions and injuries.
I agree to inform the therapist of any changes in my health and medical condition and that there shall be no liability on the therapist's part should I forget to do so.
I understand that massage is entirely therapeutic and non-sexual in nature.
I understand that healing is not linear and some pain and/or discomfort may remain after your session. I will contact Cypress Bodywork with any concerns.
By signing this release, I waive and release my therapist from any liability, past, present, and future, relating to massage therapy and bodywork.

Signature

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Get in Touch

Questions or concerns? Reach out to us at cypressbodyworkmassage@gmail.com or 850.509.2311