• HEALING TOUCH THERAPY SPA

  • Mobile Massage & Bodywork — New Client Intake Form

  • Please complete this form before your first appointment. This information helps your therapist provide appropriate, individualized care. Completing this form does not guarantee that every requested service is appropriate; your therapist may modify, postpone, or decline treatment when necessary.

  • 1. CLIENT INFORMATION

  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • 2. HEALTH & MEDICAL HISTORY

  • Please answer all questions accurately. If you answer YES, provide details in the explanation field below.
  • Have you been diagnosed with a medical condition that may affect massage/bodywork?
  • Have you had surgery, a cosmetic procedure, or hospitalization within the past 12 months?
  • Are you currently pregnant or recently postpartum?
  • Do you have or have you ever had a blood clot, DVT, pulmonary embolism, or clotting disorder?
  • Do you have a cardiovascular or circulation condition?
  • Do you have blood-pressure concerns?
  • Do you have diabetes or blood-sugar concerns?
  • Are you currently receiving cancer treatment or have you recently completed treatment?
  • Do you have osteoporosis or a condition affecting bone strength?
  • Do you have a neurological condition, seizure disorder, or altered sensation?
  • Do you have a respiratory condition that may affect treatment?
  • Do you have varicose veins or significant swelling/edema?
  • Do you have a skin condition, rash, open wound, infection, or contagious condition?
  • Do you have an injury, acute pain, unexplained pain, or limited range of motion?
  • Are you taking prescription or over-the-counter medications that may affect treatment?
  • Are you taking blood thinners or medications that affect bleeding/bruising?
  • Do you have allergies or sensitivities to fragrances, oils, lotions, herbs, or topical products?
  • Do you have an implanted medical device or other medical restriction? YES / NO
  • Has a healthcare professional given you restrictions or told you to avoid massage/bodywork? YES / NO

  • 3. TODAY'S GOALS & TREATMENT PREFERENCES

  • 4. CLIENT DISCLOSURE & INFORMED CONSENT

  • I understand that massage and bodywork are wellness and therapeutic services and are not a substitute for medical diagnosis, medical treatment, or emergency care. I agree to provide complete and accurate health information and to notify my therapist of any change in my health, medications, injuries, surgeries, pregnancy/postpartum status, or medical restrictions.

    I understand that the therapist may modify, stop, postpone, or decline treatment if information or circumstances indicate that treatment may be inappropriate or unsafe. I agree to communicate discomfort, pain, dizziness, numbness, or other concerning symptoms during the session.

    I understand that no specific outcome or result is guaranteed. I authorize Healing Touch Therapy Spa to provide the services I request after discussion with the therapist.

  • MOBILE SPA SAFETY & LIABILITY POLICY

    For your safety, all clients are expected to use caution when entering, exiting, and moving throughout the Healing Touch Therapy Spa mobile unit. Please use all provided steps, handrails, and safety supports and request assistance whenever needed.

    Clients with mobility limitations, recent injuries or surgeries, balance concerns, or other conditions that may affect their ability to safely enter, exit, or receive services must notify Healing Touch Therapy Spa before their appointment.

    Massage therapy, stretching, bodywork, and spa services may involve normal and inherent risks, including temporary soreness, tenderness, bruising, dizziness, or discomfort. Clients are responsible for providing complete and accurate information regarding relevant medical conditions, injuries, medications, surgeries, pregnancy, allergies, and physical limitations.

    By entering the mobile spa and voluntarily participating in services, clients acknowledge and assume the ordinary and inherent risks associated with the services and the mobile spa environment. To the fullest extent permitted by law, Healing Touch Therapy Spa is not responsible for injuries resulting from a client's failure to disclose relevant health or mobility information, failure to follow reasonable safety instructions, the client's own actions or negligence, or ordinary inherent risks associated with the services.

    Clients should immediately inform their therapist of any pain, discomfort, dizziness, mobility difficulty, or other concern. Healing Touch Therapy Spa reserves the right to modify, postpone, or decline a service when there is a reasonable safety or health concern.

  • Date [Date]*
     - -
    2 digit month, 2 digit day, 4 digit year

  • HEALING TOUCH THERAPY SPA

  • Mobile Appointment & Travel Authorization Form

  • Complete this form for each mobile appointment or whenever your service location changes. Accurate access and parking information is required so the mobile spa can arrive and set up safely.

  • 1. APPOINTMENT INFORMATION

  • Appointment Date Requesting
     - -
    2 digit month, 2 digit day, 4 digit year
  • Appointment Time Requesting
  • Format: (000) 000-0000.

  • 2. PROPERTY ACCESS & PARKING

  • Is there a safe, legal place for the mobile spa vehicle to park at the service location? YES / NO
  • Is the parking area large enough for the mobile spa vehicle? YES / NO
  • Can the vehicle access the property without a narrow/blocked driveway, steep grade, gate, low clearance, low-hanging branches, wires, or other hazards? YES / NO
  • Will the vehicle need a gate code, parking pass, security check-in, or special access? YES / NO
  • *
  • 3. MOBILE SETUP

  • 4. TRAVEL / MILEAGE

  • Travel fees are based on the service location and the applicable mobile-service pricing/policy shown at booking.

  • 5. PAYMENT AUTHORIZATION

  • *

  • 6. MOBILE SERVICE AGREEMENT

  • I understand that Healing Touch Therapy Spa provides mobile services at client-selected locations. I am responsible for providing accurate location, access, and parking information and for obtaining any permission required by the property owner, hotel, apartment community, HOA, office, or event venue.

    I understand that the therapist may decline or stop service when the location presents an unsafe condition, cannot be legally accessed/parked, is unsanitary, or otherwise prevents safe professional service.

    I understand that mobile travel time, mileage, parking, tolls, and other disclosed location-related charges may apply according to the pricing shown at booking.
  • Date [Date]*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: