CBD Herbal Massage Intake Form

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you a student?

Yes

No

Have you ever had a professional massage before? *

Yes

No

Have you heard about CBD (Cannabidiol)?

Yes

No

If yes, have you ever used CBD before? *

Yes

No

If yes, how?

Internally

Externally

Vape

Do you have any difficulty lying on your front, back, or side? *

Yes

No

Do you have any allergies to oils, lotions, or ointments? *

Yes

No

Do you have sensitive skin? *

Yes

No

Please check if you are wearing any of the following:

Contact lenses

Dentures

Hearing Aids

Hairpieces

Is there are particular area of the body where you are experiencing tension, stiffness, pain, or other discomfort? *

Yes

No

Do you have any particular goals in mind for this massage session? *

Yes

No

Have you ever had any surgery or hospitalizations? *

Yes

No

Have you ever been involved in an injury or auto accident? *

Yes

No

Are you currently taking any medications? *

Yes

No

Are you currently under medical supervision? *

Yes

No

Are you pregnant? *

Yes

No

Please check any conditions listed below that applies to you: *

Skin conditions (ie rash, acne, eczema)

Open sores or wounds

Bruises easily

Recent accident or Injury

Recent fracture

Recent surgery

Artificial joint

Sprains/strains

Current fever

Swollen glands

Allergies/ sensitivity

Heart condition

High or low blood pressure

Circulatory disorder

Varicose veins

Atherosclerosis

Osteoporosis

Epilepsy

Headaches/Migraines

Cancer

Diabetes

Decreased sensation

Back/neck problems

Fibromyalgia

Carpal tunnel Syndrome

TIMJ/jaw pain

Tennis elbow

Phlebitis

Hepatitis (A,B,C, other)

Stroke

Scoliosis

Seizures

Constipation/Diarrhea

Diverticultitis

Depression, panic disorder, other psych conditions

HIV/AIDS

Lupus

Deep vein thrombosis/blood clots

Joint disorder/ Rheumatoid arthritis/ Osteoarthritis/Tendonitis

Chemical Dependency

None of the above

Have you flown on a plane recently? *

Yes

No

Please read and type your name below to acknowledge that you have read and understand the following: *

1. I am aware that draping will be used during the massage session so only the area being worked on will be uncovered. 2. I understand that my feedback is an essential element in my treatment, therefore if at any time I should become uncomfortable during the massage, I may bring it my therapist's attention. 3. If I am unable to keep an appointment, I understand that a 24-hour notice is required, otherwise I will be charged a $50 cancellation fee. 4. It is my responsibility to explain and discuss all physical conditions with my Massage Therapist so that s/he may do his/her job. 5. The Massage Therapist does not diagnose or prescribe for medical illness, disease or any other physical or mental disorder. 6. The Massage Therapist does not do spinal manipulations. 7. Massage Therapy is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for any ailment that you have. 8. I have read and I fully understand this form in its entirety. If at any time there are changes in the information given or in my condition, I will notify my therapist before receiving additional massages and that there shall be no liability on the therapist’s part if I fail to do so.

First Name

Last Name

Consent to Treat *

I hereby consent for my massage therapist to treat me with hemp based CBD massage for the above noted purposes including such assessments, examinations and techniques, which may be recommended, by my therapist. I acknowledge that the therapist is not a physician and does not diagnose illness or disease or any other physical or mental disorder. I clearly understand that massage therapy is not a substitute for a medical examination. It is recommended that I attend my personal physician for any ailments that I may be experiencing. I acknowledge that no assurance or guarantee has been provided to me as to the results of the treatment. I acknowledge that with any treatment there can be risks and those risks have been explained to me and I assume those risks. I consent to the use of Hemp based CBD being applied topically during my CBD massage. I understand that Hemp CBD has less than 0.3% THC and will not cause any psychoactive symptoms to occur. I have discussed the use of topical Hemp based CBD with my health care provider and they have cleared me for use during my massage. I acknowledge and understand that the therapist must be fully aware of my existing medical conditions. I have completed my medical history form as provided by my therapist and disclosed to the therapist all of those medical conditions affecting me. It is my responsibility to keep the massage therapist updated on my medical history. The information I have provided is true and complete to the best of my knowledge. I have read the above noted consent and I have had the opportunity to question the contents and my therapy. By signing this form, I confirm my consent to treatment and intend this consent to cover the treatment discussed with me and such additional treatment as proposed by my therapist from time to time, to deal with my physical condition and for which I have sought treatment. I understand that at any time I may withdraw my consent and treatment will be stopped.

First Name

Last Name