Ace Of Cups | Intake Form

Ace of Cups Massage Intake Form

  • Date Format: MM slash DD slash YYYY
  • Health History (please check all that apply)

  • Are you under the age of 17?  If yes, you must have the written consent of your parent or guardian to participate in our massage therapy services.

    The massage therapist will not perform a breast massage on female clients without the written consent of the client prior to the massage session.  Draping will be used during the massage session unless otherwise agreed to by both client and therapist. If the client is uncomfortable for any reason, the client may ask to end the massage session, and the session will be ended.

    Massage therapy is not a substitute for medical examination or diagnosis.  It is recommended that I see a physician for any physical ailment that I may have.  I understand that the massage therapist does not prescribe medical treatments or pharmaceuticals, and does not perform any spinal adjustments.  I am aware that if I have any serious medical diagnosis, I must provide a physician’s written consent prior to service.

  • Date Format: MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.