• Client Intake Form

    Client Intake Form

    All information is confidential and will not be shared or disclosed without your written consent.

  • If you are a new client or have not been in within the last 12 months, please fill out this Client Intake Form. 

    If you have been to see us within the last 12 months, it is not necessary to fill out this Intake Form, unless you have had significant changes to your health history.

  • When is your appointment?*
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    2 digit month, 2 digit day, 4 digit year
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  • Email*
  • Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
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  • What would you prefer during your massage session?

  • Are you currently pregnant?*
  • When is your due date?*
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    2 digit month, 2 digit day, 4 digit year
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  • Medical History*
    Rows

  • POLICIES

     

    COMMUNICATION:  It is imperative that you, as the client, communicate with your therapist as to whether the pressure is too light or too deep, or any issues.  The therapist will tailor your massage and their techniques the best they can, but they cannot read minds, so it is essential you communicate with therapist.

    WATER:  I understand that it is recommended to remain hydrated and drink plenty of water after my massage.  Some symptoms that may occur if not enough water has been consumed are: headache, dizziness, lightheadedness, sore muscles, fatigue and weakness.

    ALCOHOL:  Consuming alcohol within 48 hours of the massage can intensify the effects of alcohol in your body.  Some symptoms that may occur if you consume alcohol: headache, aching, fatigue, lightheadedness, sore muscles and weakness.

    CONDUCT: I understand there shall be no sexual contact, sexual conversation or innuendos at any time. If so, the massage will stop immediately and full payment is still required due to the time that was allotted for the appointment.

    FRAUD: I understand it is fraud to misinform the massage therapist of any medical condition or medication I am taking or not taking. I have truthfully answered all the questions honestly. I shall not hold the massage therapist or The Massage Store liable for any negative reactions to the massage treatment in the unlikely event any should arise.

    DIAGNOSING:   I understand the massage therapist is not licensed to diagnose an illness or disease nor prescribe medications and will not do so.

    CANCELLATION POLICY:  I understand that there is a 24 hour cancellation policy, and that anytime I no-show or cancel/reschedule less than 24 hours prior to my appointment time, I will be billed for the full amount of the appointment.

    SICKNESS: Please reschedule your appointment as soon as you are aware of an infectious or contagious condition. If you arrive for your appointment with symptoms of an illness, you will kindly be asked to reschedule your appointment to avoid the spread of germs. If any of the following describes you or someone you have been in close contact with, we kindly ask that you reschedule your appointment so we can prevent the spread of bugs: 

    • Fever or Chills
    • Shortness of Breath
    • Loss of Taste or Smell
    • Vomiting or Diarrhea 
    • Runny Nose 
    • Sore Throat or Cough
    • You have a skin infection. 
    • Cold, sinus infection, or flU.
    • Possible exposure to COVID-19.
  • COVID-19 Screening: Do you have any of the following symptoms?*

  • In the last 7 days, have you been in close contact with anyone exhibiting any of the above symptoms or someone that has been exposed to/diagnosed with COVID-19?*

  • Informed Consent

  • By typing my first name, last name, and providing my e-signature below, I am indicating the following: 

    1. I have read and completed the Client Intake Form for The Massage Store accurately and to the best of my knowledge.

    2. I consent to a massage/bodywork session at The Massage Store by a licensed massage therapist.

    3. I have read the cancellation policy and agree to abide by it.

    4. I am healthy and do not have any symptoms of illness, including, but not limited to, the symptoms listed above under the Sickness Policy.

  • Signature*
  • Today's Date*
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  • Should be Empty: