Massage Intake Form
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Have you ever had a professional massage before?
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Are you sensitive to fragrances or perfume?
Do you have sensitive skin?
Do you wear contact lenses?
Do you exercise regularly?
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Do you see a chiropractor?
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Please indicate any conditions that you have had or currently have:
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Draping will be used during the session – only the area being worked will be uncovered. Clients under the age of 17 must be accompanied by a parent or legal guardian during the entire session. A separate informed consent sheet must be provided for any client under the age of 17.

I understand that massage is intended to enhance relaxation, reduce pain caused by muscle tension, increase range of motion, improve circulation, and offer a positive experience of touch. If I experience any pain or discomfort during the session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort.

I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a chiropractor, physician or other qualified medical specialist for any mental or physical ailment that I am aware of. 

I 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 therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so.

In our commitment to provide a unique and outstanding massage experience to all of our clients and out of consideration for our therapist’s time, we have adopted the following policies: We require a 24-hour cancellation notice for any massage appointment except in case of illness, emergency or weather.

A cancellation or missed appointment under the 24-hour window will result in a $80 missed appointment fee. Please arrive at least 5 minutes before your scheduled massage. This allows time for the therapist to go over any health-related questions with you. If you arrive more than 15 minutes late for your appointment, you will be charged the $80 missed appointment fee.

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The undersigned hereby authorizes the release of any information relating to claims for the benefits submitted. I further agree and authorize my physician to submit claims for the benefits and for services rendered, without obtaining my signature on each claim.

I also authorize my insurance company to pay and assign directly to Seattle Wellness Group, PS. and/or Seattle Chiropractic & Massage Center all owed benefits. I understand I am ultimately financially responsible for all charges incurred. 

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Please do not submit any Protected Health Information (PHI).

Location

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Seattle Chiropractic and Wellness Group

Address

3611 Woodland Park Avenue North
Seattle, WA 98103, US

Contact Information (206) 826-1005

(206) 826-1289

[email protected]

Office Hours

Monday  

9:00 am - 6:00 pm

Tuesday  

9:00 am - 6:00 pm

Wednesday  

9:00 am - 6:00 pm

Thursday  

10:00 am - 7:00 pm

Friday  

9:00 am - 5:00 pm

Saturday  

8:00 am - 4:00 pm (acupuncture only)

Sunday  

Closed