What are common contraindications to flag?

Recent surgery, blood clots/DVT, uncontrolled high blood pressure or heart conditions, fever or infection, certain skin conditions, and pregnancy (which needs trained prenatal technique and often physician clearance). The therapist may decline or modify treatment in these cases — the form documents the screening and the consent.

Is health information on this form private?

Yes — treat it as confidential. Depending on your practice it may be subject to HIPAA, and state privacy laws may apply broadly to health information. Store completed forms securely, limit access, and dispose of them per your retention policy.

Does the consent cover everything legally?

It documents informed consent and professional boundaries (draping, non-sexual, may decline/modify), which is important — but it is a template, not legal advice, and does not replace your professional judgment, proper licensure, or liability insurance. Adapt it to your state's board requirements and have it reviewed if you have concerns.

What are common contraindications to flag?

Recent surgery, blood clots/DVT, uncontrolled high blood pressure or heart conditions, fever or infection, certain skin conditions, and pregnancy (which needs trained prenatal technique and often physician clearance). The therapist may decline or modify treatment in these cases — the form documents the screening and the consent.

Is health information on this form private?

Yes — treat it as confidential. Depending on your practice it may be subject to HIPAA, and state privacy laws may apply broadly to health information. Store completed forms securely, limit access, and dispose of them per your retention policy.

Does the consent cover everything legally?

It documents informed consent and professional boundaries (draping, non-sexual, may decline/modify), which is important — but it is a template, not legal advice, and does not replace your professional judgment, proper licensure, or liability insurance. Adapt it to your state's board requirements and have it reviewed if you have concerns.

Massage Therapy Intake & Consent Form

A massage therapy client intake and informed-consent form — contact and emergency info, health history and current conditions, medications and allergies, pain/focus areas and areas to avoid, pregnancy status, contraindication screening, an informed-consent statement, and signature.

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Calm Hands Massage Therapy
MASSAGE THERAPY INTAKE & CONSENT FORM

Therapist: Jamie Lee, LMT Date: June 12, 2026

1. CLIENT
Name: Alex Morgan DOB: March 14, 1990
Phone: +1 415 555 0192 Email: alex.morgan@example.com
Emergency contact: Sam Morgan — +1 415 555 0188

2. TODAY'S VISIT
Reason / goals: Chronic neck & upper-back tension from desk work; relaxation. Prefer medium-firm pressure.
Areas of pain / focus: Upper traps, base of neck, right shoulder.
Pressure preference: Medium-firm

3. HEALTH HISTORY
Medical conditions / history: No heart conditions, high blood pressure, diabetes, blood clots, or recent surgery. Occasional migraines. History of mild lower-back strain (2024, resolved).
Current medications: None routine; ibuprofen as needed.
Allergies / skin sensitivities: Sensitive to strongly scented products; prefer unscented oil. No nut-oil allergy.
Recent injuries / surgeries: None in the past 12 months.
Pregnant: No / not applicable.

4. AREAS TO AVOID
Please avoid the abdomen and the left forearm (recent bruise).

5. INFORMED CONSENT & ACKNOWLEDGMENT
I understand that massage therapy is provided for general relaxation and the
relief of muscular tension, and is NOT a substitute for medical diagnosis or
treatment. I have disclosed my health conditions, medications, allergies, and
injuries honestly, and I will tell the therapist immediately if I experience
discomfort or pain during the session. I understand the therapist may decline
or modify treatment for my safety (for example, in the case of fever, certain
skin conditions, blood clots, or contraindicated conditions), that draping
will be used to keep me appropriately covered at all times, and that the
session is non-sexual and professional. I consent to receive massage therapy
on these terms.

6. SIGNATURE
Client: _______________________________ Date: ______________
Alex Morgan

Therapist: ____________________________ Date: ______________
Jamie Lee, LMT

About this template

A massage therapy intake and consent form is both a clinical safety tool and a professional-standards record — most state licensing boards and liability insurers expect therapists to screen clients and obtain informed consent. The health-history section exists to catch **contraindications**: conditions where massage should be modified or avoided (recent surgery, blood clots/DVT, uncontrolled high blood pressure or heart conditions, certain skin conditions, fever) and details that change the session (medications, allergies to oils/lotions, recent injuries). Two fields do outsized safety work: **areas to avoid** (a recent bruise, a healing incision, a sensitive area) and **pregnancy status**, since prenatal massage requires appropriate training, positioning, and often physician clearance — especially in the first trimester or a high-risk pregnancy. The **informed-consent statement** is what protects both client and therapist: it makes clear that massage is for relaxation and muscular relief and is **not medical diagnosis or treatment**, that the client has disclosed their history honestly and will speak up about discomfort, that the therapist may decline or modify treatment for safety, and that **draping is used and the session is strictly professional and non-sexual** — language that sets boundaries and is increasingly expected. A few practices matter: collect the form before the first session, **store it securely** (health information may be subject to HIPAA for some practices and to state privacy laws broadly), update it when a client's health changes, and remember the form supports — but does not replace — the therapist's own assessment and professional judgment. Keep it to one page and make the consent language plain.

When to use it

Onboarding a new massage therapy client before the first session.
Screening for contraindications and areas to avoid.
Recording health history, medications, allergies, and goals.
Obtaining informed consent and a signature.

What to include

Client contact and emergency info.
Reason for visit, focus areas, and pressure preference.
Health history, medications, allergies, injuries, and pregnancy status.
Areas to avoid and contraindication screening.
Informed-consent statement (not medical care; draping; professional) and signature.

Frequently asked

To screen for contraindications and provide safe, appropriate treatment, and because most state licensing boards and liability insurers expect it. The form captures health history, medications, allergies, injuries, areas to avoid, and pregnancy status, plus informed consent — protecting both the client and the therapist.

⚠ Legal disclaimer. This massage therapy intake and consent form is a general template, not legal or medical advice. Massage therapists are licensed and regulated by state, and intake/consent requirements and contraindication standards are set by state boards and professional bodies; massage is not medical diagnosis or treatment. Client health information may be subject to HIPAA and/or state privacy laws — store it securely. Have the form reviewed against your state board's requirements and carry appropriate liability insurance.

Jurisdiction: General — a massage therapy client intake and informed-consent form. Massage therapists are licensed/regulated at the state level (most states require licensure); intake and consent are professional-standard and often required by licensing boards and liability insurers. Health information collected may be subject to privacy laws (HIPAA applies to some practices; state privacy laws may apply broadly) — store it securely. Massage is not medical diagnosis or treatment.

Last reviewed: 2026-05

Reviewed by ScoutMyTool — consult a licensed attorney for binding use.