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  • English (US)
  • Soulrenity Wellness Spa & Boutique, LLC

    218 E. Lexington St., Ste. #504

    Baltimore, MD 21202

     

    Massage Therapy Intake Form

    All information is held in the strictest of confidence. At no given point will information be disclosed or shared with third parties without the client’s written consent. Please answer each question to the best of your knowledge. Providing accurate information helps us to better plan your treatment of care.

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  • History of Pathology

  • Please check any symptoms that apply to you and indicate right or left when applicable:

  • Massage Therapy Session Policies:

    Client services and chart information are confidential. Written authorization is required from you to release any information to third parties.

    • Masks are to be worn before, during and after your session

           • Please turn your cell phone to silent for optimal relaxation

           • Your scheduled session is set aside for you. We do not double book appointments, therefore please arrive 15min prior to your scheduled session

           • Please reschedule your session if you are more than 10 minutes late. Please plan accordingly

    ***If you are feeling sick or recovering from being sick/ill, please reschedule for a later date no less than 2wks later from your original appointment***

           • 6 hour cancellation notice is required to avoid being charged a cancellation fee of $35 for your session

           • You will be draped and at no time will genitalia or breast tissue be exposed

           • You will have a consultation with your therapist to discuss your session

           • Should the session require, after your therapist has left the room, you may disrobe to your comfort level and proceed to get under the blanket and the sheet of the massage table

           • Inappropriate behavior be it gestures, touching or speech will not be tolerated and your appointment will be discontinued immediately and you may be prosecuted to the full extent of the law

           • We do not offer REFUNDS

    Client Agreement:

    I understand that therapeutic massage therapists do not diagnose illness, disease, any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or perform joint mobilization.

    I acknowledge that massage therapy is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service.

    It is my choice to receive therapeutic massage as a form of therapy.

    I understand that my therapeutic massage therapist or I may end the session at any time for any reason

    I understand that treatment given is designed to address the care and prevention of myofascial pain and dysfunction, to provide relaxation and an overall feeling of well being.

    I also undersand that at any time I feel pain or discomfort during the session, I will immediately inform my therapeutic massage therapist so they can adjust. 

    I have stated my pertinent medical conditions, and will update the massage therapist of any changes in my health status.

    I understand that my failure to do so may pose a threat to my health and/physical well being and I hold harmless Soulrenity Wellness Spa & Boutique, LLC, it's board, associates, partners, independent contractors, affiliates, employees, representatives, successors and my therapeutic massage therapist from any liability whatsoever arising from failure to do so on my part.

    By my electronic signature below, I agree to the massage therapy policy and client agreement above. 

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