MFR Center Client Intake Form

Please fully complete the Intake Form below before your first session.

If you answer “yes” to any of the following questions, please explain as clearly as possible in the additional comments section at the end of the list.

BY CLICKING THE SUBMIT BUTTON BELOW, I AGREE TO THE FOLLOWING:

I understand that the bodywork I receive is provided for the basic purpose of relaxation and release of muscular tension. If I experience any pain or discomfort during the session, I will immediately inform the practitioner so the pressure and or strokes may be adjusted to my level of comfort. I further understand that bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialists for any mental or physical ailment of which I am aware. I understand that bodywork practitioners 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 should be construed as such. Because bodywork should not be performed under certain medical conditions, I affirm that I have stated all my own medical conditions and answered all questions honestly. I agreed to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.