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Massage Therapy Intake Form

Please complete it before your appointment

Massage Therapy Intake Form








Therapy Consent:

I understand that the session I receive for massage therapy by the Certified Massage Therapist are for the purpose of stress reduction, muscular tension & general relaxation.

I also understand the Certified Massage Therapist does not diagnose illness, disease or any other physical or mental disorder.  As such, the practitioner does not prescribe medical treatment or pharmaceuticals, nor do they perform any spinal manipulations or treat, prevent or cure any disease.  I understand that clinical massage therapy is not a substitute for medical treatment and that it is recommended that I see a physician for any physical ailment(s) that I may have.

I have stated all my known medical condition(s) & take it upon myself to keep the practitioner updated in writing before any sessions on changes in my physical health.  With that in mind, I agree to not hold the practitioner nor The Chicago Stress Relief Center, Inc. liable for any problems that may arise as a result of my session.

Payment is due at the time of the session(s) unless other arrangements have been made in advance.  I also understand that I am responsible for payment if third party payment is not made.

24-Hour Cancellation Policy & Credit Authorization Release

We take great pride in the quality of care we offer our patients. In order to do this we have a strict cancellation policy.  The Chicago Stress Relief Center, Inc. requires a 24-hour cancellation notice prior to your appointment time.  If sufficient time is not given, the full fee will be charged to the credit card we have on file.