Intake Form - Lilah Rose Massage

Intake Form 6.15

First Name

Last Name

Street Address

City

State

Zip Code

Cell Phone Number

Alternate Phone Number

Preferred method(s) of communication:

text message

phone call

Age

Date of Birth

Occupation

Emergency Contact

Name

Phone

Relationship

How did you hear about Lilah Rose Massage? Referred by:

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?

Yes

If yes, how recent?

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

Yes

If yes, please explain.

3) Do you have any special needs I should prepare for?

Yes

If yes, please describe.

4) Do you have any allergies/sensitivities to oils/lotions/ointments or scents?

Yes

If yes, please explain.

5) Do you have sensitive skin?

Yes

Are you ticklish?

Yes

If yes, are there areas I should avoid or be careful around?

6) What type of pressure do you prefer?

Deep

Medium

Light

7) Do you sit or stand for long hours at work, computer, or driving?

Yes

If yes, please describe.

8) Do you perform any repetitive movements in your work, sports or hobbies?

Yes

If yes, please describe.

9) Is there a particular area of the body where you are currently experiencing tension, stiffness, pain or other discomfort?

Yes

If yes, please identify.

10) Do you have any particular goals for this massage session?

Yes

If yes, please explain:

Medical History

11) Are you currently under medical supervision or taking any medications?

Yes

If yes, please explain/list:

Please explain any condition that you have marked above and anything else about your health history that you think would be useful for your massage practitioner to know to plan a safe and effective massage session for you:

Please read ALL of the below and click "submit" at the bottom.

Policies

Sick Policy

Massage/bodywork is not appropriate care for infectious or contagious illness. Please cancel your appointment as soon as you are aware of an infectious or contagious condition. If it is within the 24-hour notice period, the cancellation fee may be waived.

Missed Appointment and Cancellation Policy

If you are unable to keep a scheduled appointment, please give at least 24 hours advanced notice, to ensure that you will not be charged for the appointment.

Amid the ongoing uncertainty of COVID-19, we have modified our cancellation policy to offer greater flexibility to all our clients in the case of illness. If you have any respiratory or flu-like symptoms, including fever/chills, sore throat, cough and/or shortness of breath, please stay home, rather than feel obligated to keep your appointment. Please let us know as soon as possible. We will not charge you for a late cancellation if you are sick with a cold or flu.

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...

The massage/bodywork I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during the session, I will immediately inform the practitioner so that the treatment, pressure and/or strokes may be adjusted to my level of comfort.
Massage/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 specialist for any mental or physical ailment of which I am aware. I understand that massage/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 given should be construed as such.
Because massage therapy/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree 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.
Any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be responsible for full payment of the scheduled appointment.

I have read and agree to all of the above policies.

Confidential Massage Client Intake Form

Medical History

Policies

Sick Policy

Missed Appointment and Cancellation Policy

Arriving Late

I understand that...