Client Intake Form, Consent to Treatment of Sensitive Areas and Liability Waiver

Client Intake & Consent Form
New FormUpdated Form (please fill out if it has been one year since your last visit)
Full Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email*
example@example.com
Gender/Pronoun:
Birth Date

MonthDayYear
Emergency Contact*
Phone Number*

Area CodePhone Number
Occupation:
Where did you hear about us?
If word of mouth, please let us know who referred you! We'd like to give them a gift!

First NameLast Name
Describe your experience with Thai Massage:
Thai massage is an ancient Buddhist practice. Have you had a Thai massage before?*

YesNo
Describe your preference for pressure:
Treatment goals:
Medical history:
Any major illness, injuries, accidents or surgical procedures?
Do you have any restriction in movement/stretches?
Please list all supplements and medications that you are currently taking
Cardiovascular

High blood PressureLow blood pressureChronic congestive heart failureHeart attackPhlebitis/varicose veinsStroke/CVAPacemaker or similar deviceHeart Disease
Head / Neck

HeadachesMigrainesVision problemsEar problemsHearing loss
Respiratory

Chronic coughShortness of breathBronchitisAsthmaEmphysema
Infections

HepatitisSkin conditionsTBHIVHerpes
Women: Gynecological conditions? Pregnant?
Other conditions

Loss of sensationDiabetesAllergies/hypersensitivityEpilepsyCancerSkin conditionsArthritisInternal pins, wires, artificial joints, or specific equipment
Please specify if you selected any of the options under other conditions:
Please circle any areas of concern that may affect your treatment.
Please list anything you feel we should know before your Thai massage:
Informed Consent for Treatment of Sensitive Areas

During a traditional Thai massage, treatment to sensitive areas (gluteals, chest wall, and inner thigh) are likely to be included in a standard treatment. The purpose of treating these areas is, in general, to remain in accordance with a general principle of traditional Thai massage practice, which is to treat the body as a whole and not to neglect any one part. The benefits and risks of treating these areas are no different than the treatment of any other area of the body. Some benefits include increased muscle relaxation, improved range of motion, and an overall decreased feeling of stress. Some risks include short-term bruising and muscle soreness.

By signing this section, you understand what and where the sensitive areas listed above are, and you acknowledge that your therapist may treat those sensitive areas based on their clinical impressions, assessments, and with respect to the practice of Traditional Thai massage. You acknowledge that any treatment to these areas is strictly for therapeutic purposes. You also understand that you have the right to modify and/or stop the treatment at any time and that is your responsibility to do if you feel uncomfortable with any aspect of the treatment. You may also choose not to sign this form, in which case the therapist will avoid treatment to the specified areas.
Please check off any sensitive areas you do NOT want included in the treatment:

GlutealsChest wallInner thighOther
The time slot allocated for your appointment is exclusively set aside for your benefit. If you happen to cancel or miss the appointment at short notice, it creates a gap in our therapists' schedule that could have accommodated another client.

In accordance with our Cancellation Policies we therefore require a Credit Card to hold all bookings. Cancellation within less than 24 hours notice (48 hours for Couples and Groups) or missed appointments will be charged the full amount to the credit card on file.
By signing this document you agree with the above statements.
Date*

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Date
Signature*

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Client Intake & Consent Form