Massage Intake Form

Please check any symptoms that apply:

CANCELLATION & NO SHOWS

We require at least 48 hours notice to cancel an appointment. Clients who cancel an appointment with less than 48 hours notice will be charged the non refundable deposit of $50. Clients who cancel within the 48 hours notice will get a credit of $25 from their $50 nonrefundable deposit. Clients who do not show up for a scheduled appointment or notify us in advance will not receive the non refundable deposit, and may be declined future services. We understand that emergencies and illnesses can arise, therefore last minute cancellations due to things such as verifiable emergencies, illnesses or inclement weather will generally not result in any missed session charges, however this is to be determined at the practitioner's discretion.

LATE ARRIVAL POLICY

All scheduled appointments will end at the scheduled ending time in order for us to stay on schedule. Clients who arrive late to their scheduled appointment will be charged for the full session and will not receive a time extension. Please arrive 5 minutes before your scheduled appointment time to allow time to undress and get on the table to enjoy a relaxed and unhurried experience.

MASSAGE TERMINATION

Only professional massage and bodywork services for relaxation or therapeutic purposes are offered at this massage practice. Massage services will be terminated immediately in the event of inappropriate conduct of any kind. This includes harassment, threatening speech or behavior, sexual advances or requests, or disrespectful actions or language. A session will not be conducted if the client is under the influence of drugs or alcohol. If the massage is terminated for any of these reasons, full payment for the scheduled session is still required.

DRAPING POLICY

Clients will be appropriately draped with a sheet and/or towel at all times during their massage. Only areas of the body that are currently being treated will be exposed. The breast and genital areas will always remain draped and are never massaged.

Signing below indicates that you have read, fully understand and will abide by the massage policies as listed above.

By signing below, you agree to the following:

1. I voluntarily request and consent to receiving massage therapy.
2. I understand that the massage service offered is for the purpose of general wellness, stress reduction, and
   relief of muscular tension only.
3. I do not have any injuries or conditions that prevent me from receiving massage therapy.
4. I understand the importance of informing my massage therapist of all medical conditions and medications that I am taking, and that there may be additional risks based on my physical condition.
5. If I experience any pain or discomfort, I will immediately inform my therapist so that the pressure or techniques used can be adjusted to my comfort level. I will not hold my massage therapist responsible for any pain or discomfort I experience during or after the session.
6. I understand the risks associated with massage therapy include, but are not limited to:

   Superficial bruising

   • Short-term muscle soreness

   • Exacerbation of undiscovered injury

   • I have not received a positive test for coronavirus within the past 14 days, and currently have no symptoms.

   • I do not have any contagious conditions that may put my massage therapist or other clients at risk.

7. I understand that I or the massage therapist may terminate the session at any time.
8. I have been given the opportunity to ask questions about massage therapy and my questions have been answered.

 I have been advised of the policies and procedures pertaining to massage and I understand these policies. Information regarding massage in general, benefits, contraindications of massage, and possible alternative therapies have been explained to me.

I further understand that massage therapy is not a substitute for a medical examination or treatment, and that I should see a physician or other qualified health specialist for any mental or physical ailment of which I am aware. I understand that massage therapists do not diagnose illness or disease, and nothing said during the massage should be construed as such. My consent is informed and voluntary and I understand that I may withdraw my consent at any time except for actions already taken.

By signing this form I give my consent to proceed with the massage service as outlined above.

1. Massage sessions will begin and end at the scheduled time. Sessions that begin late due to the client's late arrival will end at the scheduled time and the client will be billed for the full time.
2. All clients will be treated with respect and dignity. Personal and professional boundaries will be respected at all times.
3. Clients must provide an accurate health history and agree to inform their therapist of any updates or changes to their health/medical condition.
4. Any client with a contagious condition including common cold, influenza, stomach flu, coronavirus, meningitis, shingles, contagious skin conditions, etc. must not come into the office, but call to inform the therapist before scheduled appointment time. Clients may reschedule their appointment after the contagious condition has resolved.
5. Clients with signs of symptoms of an active systemic or localized infection (e.g. fever, sore throat, swelling, etc.) at the time of a scheduled massage are asked to notify their therapist and reschedule their appointment.
6. Massage therapists only provide therapeutic massage and modalities that are within the scope of practice for this licensed profession. Clients with acute injuries or conditions that are outside of the scope of practice for massage should consult with their doctor.
7. All clients will be appropriately draped with a sheet at all times during the massage session. Only the area(s) of the body that are currently being worked will be exposed. The genital area is never exposed or massaged.
8. Client privacy and confidentiality will be maintained at all times.
9. Any client who arrives under the influence of drugs or alcohol will be asked to leave.
10. This is a non-smoking, odor-neutral massage office.
11. Clients are expected to be clean and have showered prior to receiving massage (on same day).
12. All clients are provided with a competent and professional massage that focuses on the needs of each individual client.
13. Harassment of any kind is not tolerated and the session will be terminated if this occurs, or if the practitioner's safety is compromised in any way.
14. Clients are asked to avoid eating a heavy meal during the two hours prior to receiving massage.
15. Appointments are confirmed between one to two days prior to the scheduled appointment.
    
    I have read, fully understand and will abide by the massage guidelines and expectations listed above.