Confidential Intake & Consent Form

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Date of Birth
Preferred method(s) of communication:

Emergency Contact

The following information will be used to help plan safe and effective massage therapy sessions. Please answer the questions to the best of your comfort and knowledge.

1) Have you had a professional massage before?
2) Do you have any difficulty lying on your front, back, or side?
3) Do you have any special needs I should prepare for?
4) Do you have any allergies/sensitivities to oils/lotions/ointments or scents?
5) Do you have sensitive skin?
Are you ticklish?
6) Is there a particular area of the body where you are currently experiencing swelling, tingling, tension, pain or other discomfort?
7) Do you have any particular goals for this massage session?

Medical History

8) Are you currently under medical supervision or taking any medications?
9) Please check any condition listed that pertains to you:
Conditions, continued:

Please check one of the following.

I AM / AM NOT comfortable in having undraped breast work performed.

Please read ALL of the below and click "Agree & Submit Intake Form" at the bottom.

Sick Policy Massage/bodywork is not appropriate care for infectious or contagious illness. Please cancel or reschedule your appointment as soon as you are aware of an infectious or contagious condition. Missed Appointment and Cancellation Policy Please give at least 48 hours notice with cancellations. Less than 24-hours will incur full cost of your appointment. Thank you for your accountability and understanding. Arriving Late All massage sessions have a specific time schedule and an early arrival allows for a relaxed and unhurried experience. If late arrival is inevitable, your service may be shortened in order to keep on schedule and you will be expected to pay the original appointment rate. I understand that...

I understand that Massage Therapists are not medical doctors and are not substitutes for medical treatment. Massage Therapists also do not diagnose, prescribe medications, or perform spinal manipulations.

I understand that it is my responsibility to fully inform the Massage Therapist with all medical conditions, symptoms, medications, etc. I am also responsible to answer all questions about my health and physical condition honestly and in full detail. I understand that it is solely my responsibility to keep the Therapist updated on any changes in my health and physical conditions. I also understand that it is my responsibility to communicate with my Massage Therapist if I have any questions or concerns regarding my session.

I do not have any symptoms or injuries or conditions that would prevent me from receiving Massage Therapy, nor have I been told by a health care provider that I should not receive Massage Therapy. The Therapist has the right to decline, discontinue or restrict services at any time based on information that may put my own health or the Therapist’s health at risk.

I understand that massage and bodywork are therapeutic, clinical, and non-sexual. Only area(s) currently being worked on will be professionally and adequately undraped. In certain cases, undraped breast work may be performed to best move lymphatic fluid away from blocked or congested areas. I understand that having undraped breast work is performed clinically and professionally and in no way conducted in an inappropriate or sexual manner.

I understand that my Massage Therapist reserves the right to refuse treatment or end a session immediately, in the case of sexual innuendos or advances or other inappropriate behavior by the client. I also understand that I am responsible for full payment of the scheduled session.

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