New Massage Client Liability Consent Form after September 4th 2023 & revised February 29 2024

The Massage Negotiator Client Liability Form :

Required by law to massage over the age of 18 (or with separate consent form for massage of a minor), keep progressive reports of clients, protect this information by HIPPA/HIPAA regulations, maintain these client details to prevent massage and bodywork contraindications. An assessment that fully details the modalities and services provided for that session, the appointment date, time of appointment, suggestions for maintaining health and wellness and for your next massage appointment are filled in by your massage therapist and emailed to you after every appointment in 0-7 days (not required by law). You must fill in a new form every 1-2 years for any unforeseen health conditions or limitations you might need to change for your subsequent massage sessions. All massage sessions are customizable and accommodating to any new changes you might experience. After filling out this form you will receive a copy at the email you provided for your records.
Full Name*

First NameLast Name
Birth Date *

MonthDayYear
Date
gender (due to nature of service with mobile massage therapy services and body contact, we reserve the right to discriminate by gender in allowing our clients and massage therapists comfort and mutual respect for each other). If you are transgender the female to male and female clients are referred to females and the male to female and males are referred to males in most cases.*

malefemale
Please tell us what you like about massage therapy in general for you, such as: recovery from injury, stretching, relief of muscle aches, to heal faster from injury, to sleep better, to relax, to help manage stress, to mobilize my tendonous joints, to manage chronic inflammation, or other. *
Please tell us the last time you had a massage.*
Please tell us what you didn't like about your last massage.*
Please tell us where you last received your regular monthly, biweekly, or weekly massages?*
Please provide your service address if this is for mobile massage therapy services.*

Street Address

Street Address Line 2

CityState

Zip Code
If you have a gated or private entrance requiring a pin code or special instructions, please enter it now.
pin code to private entrance of massage service address
Phone Number*

Area CodePhone Number
Please enter your e-mail so that your Suggestive/Objective/Assessment/Plan (SOAP) notes on your massage session can be emailed to you with your receipt within a few days after your appointment.*

Confirmation Email
If you have a child you are purchasing a massage for and will be present the whole massage for the child, please enter your child's name.

First NameLast Name
Please enter your child's birthdate that you want massaged.

MonthDayYear
Date
Please let me know why you want your child to get a massage and if your child has ever had a massage before.
Please read the following Terms and Agreements and sign your name after reading each item below about your massage session.
Terms and Agreements for mobile massage services:

1. All mobile massage services include the first 1/2 hour drive time from Corona where the 15 freeway and the 91 freeway meet in the historical time marked by Google maps. If you live only 10 miles away, it might not be less than 30 minutes away if it is during a high traffic time that makes the commute 20-45 minutes longer. If your scheduled massage does take longer than the 30 minutes to drive to the massage address or more than 30 minutes on the way back there is a $20/30 minutes fee added to the service.

2. The correct address must be given to the massage address where the scheduled massage is to be done. If the address is not marked accurately or does not have the building in an apartment complex, the appointment is cancelled for safety concerns and a transportation fee of $40 for the appointment is assessed to the card on file.

3. Offensive language or body language that is inappropriate and makes the massage therapist uncomfortable or feel disrespected for Title IX basic human protected rights (discrimination for race, religion, gender, sexual preference, sexual identity, disability, age greater than 40 years), or class status, or nationality status, sexually or violently offensive language is not allowed or tolerated.

4. Please be ready for the massage 15 minutes before the scheduled time as this is a mobile massage service and traffic can be underestimated, but also time to set up equipment is necessary. If the massage is late up to 15 minutes beyond the scheduled start time and the Google maps history of estimated travel times says it should have been on time from the 91 freeway and the 15 freeway intersection in Corona, CA at the day of the week, holiday, and time, then you get $20 off your massage. Otherwise, if Google maps says the travel distance at that time historically leaving 30 minutes before the start time took longer than 30 minutes, than rule/item 1 above applies to Terms and agreement for mobile massage services.

5. If stairs are used in the home address, the lighter massage table that is narrower will be used. If the home address listed appointments has a first floor setting, then the wider massage table will be used, unless anybody in the scheduled appointment household to receive a massage wants a deep tissue massage, then the smaller, lightweight table will be used.

6. If using any add on services for therapeutic benefits of massage and an electrical outlet is needed to perform the service, such as for infrared light therapy, hot stones, hot towel warmer, table warmer, etc. and the service address does not have the available electrical outlet, then the service can not be provided nor will be charged nor any discount assessed if bundled in a massage promotional package.

7. Parking must be available in front of the address, or in the apartment complex, and the distance from the public parking to the massage address will be acknowledged and also time deducted from the allowed 30 minutes delivery of massage supplies to the scheduled massage appointment if the walk is a 10 minute walk for example, and not easily able to be found by building and/or floor number also requiring an elevator. If parking is not available close to or in front of the house, or the street is unsafe or not a wide street that allows cars to park on the sides and two cars able to travel in both directions along the street in front of the house with room and without one car having to stop to wait for the other car to cross before traveling down the street, then the appointment will be cancelled, and a $20 transportation for massage therapist's time will be assessed, plus any estimated transportation and delivery fees if the appointment was realized to be more than 30 minutes to and/or from the scheduled appointment.

8. Offensive settings or people in or around the massage therapist providing massage services at the massage address should be zero to minimal and in other room so that nobody bothers the massage therapist while delivering the massage to the guest, or plays with the client receiving a massage while the massage therapist is providing massage such as tickling the person or grabbing the client's body part while said client receives a massage. The massage will be terminated as it is unprofessional and makes the massage therapist feel uncomfortable and is a violation of inappropriate touch during the massage session by a professionally state association for massage therapy licensed, massage standards certification educated, and city of origin business licensed massage therapist. The client will feel uncomfortable and it would be difficult for the client at that time to trust the massage environment is going to be a relaxing one and trust the benefits of massage when another person or guest is distracting the client on the table.

9. If the client needs to talk on the phone during the massage, it comes from the massage time scheduled, but it is better to schedule a time that fits the client's budget and the time needed and set aside to receive a quiet and peaceful massage.

10. Pets are allowed to be nearby as long as they don't chew or pee on the massage table or bite the massage therapist.

11. Time to set up and time to disinfect and put away massage supplies and gratuity is included in all massage appointment prices and packages, if you want to add more for gratuity it will have to be cash.

12. Only credit card or zelle are acceptable forms of payment for booking mobile massage services.

13. Any massage address booked at a location that is more than 30 minutes of drive time according to Google Maps estimated travel time from the 91 freeway and 15 freeway in Corona, CA is paid for up front as $20/30 minutes to and from blocks past the given 30 minutes drive time including traffic according to google map estimated drive times.

14. All massage clients receiving a massage at the massage address have to agree to these Terms and Agreements and fill out this massage client intake form.

15. Any minors receiving a massage must have a form of permission from the legal guardian and/or parent that the minor may receive a massage. Minors may not be able to receive a full hour massage and the parent must be in the room or monitoring the massage in progress start to end. No more than medium pressure will be used, undergarments will be on and the upper thigh and abdomen and chest avoided in the massage of minor by massage therapist.

16. If you don't pass the biopsychosocial model for pain and mental health, you may not be allowed a massage for your aches and pains until you see a psychotherapist or counselor who approves you for massage to help with you aches and pains. You may also be advised on the pain gait theory of pain and how having any emotional or altered state of mind affects how the pain, touch, temperature, pressure, and proprioceptors of tickle and itch are perceived in the brain. This is due to the thalamus of the brain interpreting and sending out actions to all sensory except smell. Smell is tied to memory and emotion in the limbic system and you would have to purchase the $5 add-on of aromatherapy of choices Lavendar, Eucalyptus, Lemon Grass, Sweet Orange, Spearmint, Peppermint, or other aromatherapy available.

17. Please note that social media works both ways, if you leave a negative review of my business other than none, you will be not be refunded and will have our version of the details posted in response. By posting online of your experience by your massage therapist you waive your rights to privacy and discretionary rights to how the service was handled. Identifiable details such as service address, age, and full name will not be posted unless a criminal offense was done against our massage therapist so that we may inform the public as our obligated duty as professionals in the service industry of complementary alternative medicine (CAM) professions.

18. Due to social media trolls and such on various marketing sites, any type of settings that make a massage therapist uncomfortable or feel disrespected or unsafe will lead to immediate cancellation of the appointment. Full charge of the massage not re-imbursed, and an online notification to the social network circles of the details of the offender, date, location, and description of the offensive scenario or event. Even being off by one digit in the service address is inclusive of this item terms.

19. Most of these items are common sense, but they are necessary to provide a safe environment that promotes courtesy and respect, free from noise or other nonsense, to deliver the therapeutic and peaceful massage services we provide.
Do you agree to the above Terms and Agreements described for mobile massage therapy services at your service address?*

Yes
Please sign agreeing to terms and conditions for mobile massage services below with your signature.*

Clear
Please enter in today's date for agreement of terms and conditions described above for mobile massage therapy services.*

MonthDayYear
Date
Biopsychosocial model for mental health and pain interpretation. Please fill out this self-evaluation survey about your state of mental health and healing outcomes expected after receiving a massage.*

I have recently had pain that is in an area of my body, I have full function of my body part that aches, but when I start my day the pain comes back and WON'T GO AWAY with pain medication and SLEEP MAKES PAIN WORSE.I don't realize I have excruciating pain until I lay down to go to bed and then it is unbearable, so UNBEARABLE pain medication does not help.I recently had some MAJOR LIFE CHANGES that have stressed me out into changing my diet, sleep schedule, number of hours of sleep, lost a loved one even a pet counts, had no time to grieve a loved one, changed jobs, added a new overwhelming task to my daily activities such as watching over kids or elderly parents.The slightest touch by a person or pet HURTS and leaves me aching and rubbing the spot until the pain goes away. But at least the pain does go away.I have pain that is fine most times of the day, but when I am CONSTANTLY on my feet or sitting too long the old aches from a previous injury or surgery RETURN and make me want to sit down and rest.I take over the counter medication to help me through my aches and pain as needed and never have a problem with pain once it kicks in as these temporarily HELP RELIEVE my pain.I cannot sleep through the night or wake up and cannot go back to sleep and have to be up for work that I drive to feeling absolutely EXHAUSTED and FATIGUED.I have had a recent ache that feels BETTER with stretching, massage, and exercising.My body is in the best shape of its life and I am only getting a massage to help my health.
Do you prefer a female or male massage therapist or no preference?

female massage therapistmale massage therapistNo preference
Do you prefer lotion or oil?

lotionoillotion or oil, no preference
Are you a male, female, or gender fluid human?

malefemalegender fluid (male same days/female some days/no preference on identity, gender neutral)
Pressure has been an area of much variance between massage therapists and massage businesses. Here is the definition of the different types of pressure. Select which one you prefer? Note that any disorders or diseases of metabolic, endocrine, cardiovascular, immune compromised, and use of medications for depression, anxiety, psychosis, inflammatory pain, and corticosteroid or other steroid use will have no more than medium pressure.

light pressure (top surface for reaching the systemic circulation and lymphatic vessels, or the top layers of muscles in back, abdomen, feet, hands.medium pressure (deeper pressure than light pressure, but able to get into the muscle belly of the top layers of muscles in the back, legs, arms, and glutes)firm pressure (a little bit deeper than medium pressure but a broader surface and wants to spread the pressure among the middle layers of muscles and muscle fascia to pull apart muscle and myofascial adhesions)deep pressure (enough pressure to dig into the deep muscles of the back that uses less than firm broad application, applied slower than light, medium, or firm to dig through those top and middle layers of muscle or tight fascia.)super deep pressure (this is if you have very tight muscle fascia and need someone to dig into your back, glutes, forearms, calves, or pectoralis muscles by the shoulder girdle. If you need deep pressure in the hands or feet, we recommend visiting the biopsychosocial section of this form as those areas that are in need of more pressure than deep have little muscle depth and could be due to allodynia or pain fiber crossing with nociceptive and proprioceptive fibers that aren't passing on the pressure or depth of pressure to thalamus. If you request more than deep pressure, more often you will not get super deep pressure. Massage therapists get labral tears from attempting to satisfy disrupted corticothalamic sensory to a client that has allodynia. We do not provide super deep pressure.)
Please briefly describe the reason you want a mobile massage therapy session, what areas you want massaged, the pressure you want, what techniques you want, any health conditions you have, when your last massage was, if this massage is for somebody else or you, and anything else you feel you want your massage therapist to know before your massage appointment such as your building location in your apartment/condominium complex, the special parking, hours to text or call back, if cell phone service is available, or wifi service is available, and so on.
Talking during session is discouraged, but if you want to talk or ask appropriate questions or discuss your life or are talkative we understand. For our massage therapists, talking in session is highly discouraged and deeply frowned upon. Are you ok with talking during your massage session?

yesnoyes, but only about answering questions I ask about the technique, training, benefits, or other questions I may have during my massage that wasn't addressed before the massage was scheduled.
Please select the following health conditions you have that are precautions or cautions to massage:

High or Low Blood PressureDiabetesKidney diseaseCancer activeon chemotherapy or radiation therapySpinal injuries/fracturesamputated limbmissing organrecent abdominal surgeryautoimmune disorder (rheumatoid arthritis, psoriatic arthritis, systemic lupus erythematosus, fibromyalgia, ankylosing spondylitis, etc)OsteoporosisRecent Surgeries (limbs, neck, low back, shoulders, etc.)Skin AbrasionsSkin infectionsactive shingles, measles, mumps, chicken pox, other contagious skin infection currently activeTuberculosisIrritable Bowel Syndrom (IBS)On psychiatric mood stabilizers such as anti-depressants, anti-anxiety, anti-psychotics, etc.on immunosuppressants and need LMT to wear face maskcongestive heart failureepilepsy/seizures activekidney diseaselymphnodeectomyanemialiver diseasepancreatitisadrenal diseaseheart diseasehistory of strokerecent trauma that hospitalized merecent concussionpost-concussion syndromeincontinenceruptured tendon currently healingtraumatic brain injury TBIany endocrine disorderon corticosteroidscomplex regional pain syndrome, hypersensitivity to pain, allodynia, burning pain to touch anywhere in bodyrecent sprain or strain to musculoskeletal systemOther

If you are getting a massage for pain relief or management, rate your pain on a scale of 1 to 10, with 1 being the least pain ever felt by you and 10 being the most amount of pain

	1	2	3	4	5	6	7	8	9	10

1 is Least , 10 is Most

Rate your sleep cycle each week as 1 being the least amount of sleep and 10 being the most amount of sleep you could want in one week.

	1	2	3	4	5	6	7	8	9	10

1 is Least, 10 is Most

Rate how stressed you are during the week with changes that have happened in your life that you are still adjusting to or are repairing, with 1 being no stress at all and 10 being the most stress you have ever experienced in your life.

	1	2	3	4	5	6	7	8	9	10

1 is No Stress, 10 is Most Stressed Ever

Thank you for filling out your liability and consent to have massage therapy services by The Massage Negotiator. You can save the form now and email janis@themassagenegotiator.com a copy or continue filling out the optional customization of your first massage session on this form. You can also submit it as is if all required fields are filled in by clicking submit below.
Customization of Massage Session for First Time Clients
(Optional) Select the TYPE OF PRESSURE you want used most of your massage session. Given an area of your body like your back, the deep layers of your back are your erector spinae muscles along the spine and intercostal muscles of the ribs, the middle layers are your rhomboids between the shoulders of upper back, and the top or superficial layer is the trapezius of the upper and mid back and the lattisimus of the mid back. These muscles have fascia around them that can make them tight and densely packed together with adhesions or knots between and in the muscle layers and fascia. Select which pressure you want based on how deep or superficial you want your massage pressure to be. Relaxing pressure is relative to your preference. Some people relax with deeper pressure and others think it painful, while some relax with lighter pressure and others could think its unsettling.

Light (only superficial muscles reached)medium (just reaching middle level muscles, not too painful)firm (broader pressure)deep tissue (deep layer muscles)super deep tissue (very dense muscle layers and chronically inflamed muscle fascia that need more pressure, if requesting in low dense areas like hands or feet then this service is not available and is related to allodynia crossing of nociceptive and proprioceptive nerve fibers with pain and temperature nerve fibers.)
(Optional) Which type of massage modalities are you comfortable with being performed during your massage session?

Swedish (speed and pressure of application vary and don't have to be fixed, such as deep tissue with strong application and slowly to the back AND limbs)Variable Speed Sports Massage Tool (good for precise tendon and muscle adhesion pressure and percussion, or as the larger, flat, broad application with longer movements towards the heart for lymphatic drainage)Accupressure (deep tissue massage with thumbs or elbows along long muscles of body and the deeper muscle layers of body)Sports (stretching involved, can vary in speed of massage from slow and elongated strokes of fibers in muscle or fast to stimulate circulation and prepare body for events)Stretches (not the entire session, but for region specific areas such as to increase range of motion around the hips, neck, knees, elbows, and ankles)Lymphatic drainage (skin rolling and light rhythmic strokes to eliminate edema. CONTRAINDICATED CONDITIONS: liver disease, ascites, hypothyroidism untreated, diabetes untreated, CHF or other heart disease, kidney disease, other endocrine disease like pancreatitis, atherosclerosis, stroke, arterial dissection, deep vein thrombosis, peripheral embolism, contagious skin disorder/infection, Chronic Obstructive Pulmonary Disease COPD, emphysema, other pulmonary diseases, lymph node(s) removal a local contraindication to removal site, on open wounds)Myofascial release (tight, rough, and painful, without oils or lotions, done before other modalities, can be done with Chinese cupping as less painful way of using cross-frictional muscle massage to break apart adhesions in connective tissue and between muscle fibers)Reflexology of hands and feet (this is relaxing and great for people who cannot withstand a moderate amount of pressure during massage, this is also good for calming the nervous system, but not recommended if you have feet that get uncomfortably ticklish)Pre-natal not high-risk (high risk is: less than 3 months pregnant, older than 35 years, previous miscarriages, high blood pressure, gestational diabetes, ovarian or uterine cysts or tumors, endometriosis, obese, anorexic, and other conditions your doctor has diagnosed as 'high-risk' pregnancy)Pre-natal (high-risk, you have a doctor's note, the pressure will be medium at most, the neck, ankles, and thumbs avoided)Chinese Cupping (as long as you don't have cardiac disease, DVT or PE, anemia, blood thinner use, leukemia, diabetes, cancer, osteoporosis, hematomas, or skin abrasions you can have Chinese cupping done for breaking apart adhesions, increasing circulation and healing , relieving inflammation, for fibromyalgia treatment, for lymph drainage, and myofascial massage)
(Optional) Which areas do you want AVOIDED?

hairfacefeetglutial muscleslower backupper armsforearmselbowscalveshamstrings (back of legs)quadriceps (front thighs)handsneckkneespectoralis major (chest)abdomen (digestion/lymph drainage)Other
Please annotate the image or draw on it with the very lightest ink option, drawing circles and arrows where you want the majority of your massage focus and/or put 'x' on areas to avoid on your back/side of your body. If you want the right side and not the left side, put an 'R' in a circle or just write it out. The image was taken from Complete Anatomy 2022 for female body type. The midline of gluteal region and pelvic region will be avoided always.
Please annotate the image below drawing with the lightest ink option to place circles and arrows to the locations of more focus on the front of your body, and putting 'X' on the areas to avoid. This image is taken from Complete Anatomy 2022 software of the female front body but can be used for males as well. The private areas are avoided by law and personal preference i.e. breasts/chest/pelvic region/genitalia/etc.
(Optional) Select what tools of your massage therapists you want used the most when massaging you, in other words what STYLE of massage do you want? Visit https://themassagenegotiator.com/modalities to read up on some of these items.

thumbs (common)knuckles (also common if MT has long nails)fists ( for gathering tissue layers and rolling out the adhesions in the layers)Variable Speed Sports Massage Toolpalms of hands (for firm, light, and medium pressure)feet (for accupressure of large muscle areas like upper back, thighs, hamstrings, and hips)elbows (for deeper pressure)forearms (for deeper medium pressure, but not deep pressure unless the sides of body like the Tendons of the legs)Hot StonesCold StonesChinese CupsIntegrative Assisted Soft Tissue Mobilization (IASTM) toolsOpen to trying anything that workssound therapymuscle enhancement therapy (stretching active, assisted, and resisted)Other
(Optional) What are your massage goals? In other words, what do you expect to accomplish during your massage session?

increased range of motion by speeding up the healing time after injury with moderate stretching and massage to increase interaction between nutrients and improved supply of nutrients to injured area that are needed to build and repair muscle fibers, tendinous strains, or ligamentous sprains.relaxed state of mind by believing massage helps and is an added benefit to heal my body from the inside out with a healthy diet, exercise regularly, great sleep daily, managing or avoiding stress, and staying balanced in all areas of life.less to no pain in areas of my body that ache with direct contact of massage to the areas affected to balance out the pressure receptors that operate on faster nerve communication networks than the unmyelinated and slower nerve fibers for pain.less fluid build up in areas of my body that have edema by getting regular lymphatic drainage massages, staying hydrated, and committing to exercise if doctor approved to pump out the proteins making the osmotic pressure higher outside my vasculature and lymphatics than inside the veins and lymph to pull those proteins and toxins out with the added fluid accumulation.help manage symptomatic pain related to fibromyalgia based on belief that a massage helps shut down the defective proprioceptor communication between the thalamus and soft tissue, skin, and nervous tissue sites that flare up in a fibromyalgia attack.less inflammation from stress due to the corticotropin releasing hormone and cortisol stress levels increased from my autonomic nervous system in stressful eventsSleep better by activating the rest and digest response of the parasympathetic nervous system to help detox my body and open up blood and nerve pathways in my body by shutting down the sympathetic nervous system and hyperactive nerve firing to muscles that constrict blood vessels.improve circulation and healing outcomes after injury or painful muscle recovery by opening vasculature entrapment pathways caused by tightened muscle tissue, scar tissue, or adaptively shortened muscle fibers compressing vasculaturefree up soft tissue space to decompress nerves to help with symptomatic relief of compressed nerves that my body feels like pain that is sharp and shooting or electric, numbness or tingling sensations along the route of the nerve.
(Optional) Which additional services would you like to add to your massage session?

aromatherapyhot stone massagecold stone massagevariable speed massage for lymph drainagevariable speed massage for sports massage localized pain reliefinstrument assisted soft tissue (IASTM) tool, stainless steel or gua sha toolgua sha rose quarts tools for face massage and aiding in draining lymph from facekinesiology taping with sports balm/gel for pain reliefDynamic cupping for lymph drainage, myofascial massage, and/or promoting immunity and recoveryInfrared light therapy for arthritis pain reliefRadiofrequency vacuum for lipocavitation lymphatic drainage aid
For the below selection, you can find additional information on the requirements for each massage package by visiting: service information.
Which mobile massage bundled savings packages are you interested in for you and/or your family to fit in a regular wellness plan through massage services into your schedule?

family massage special (4 hours of massage for as many family members to split time between for $200)manual lymphatic drainage (ten 1-hour sessions $55 each, $550 prepaid)monthly membership (four 1-hour massage sessions per month, $200)
(Optional) How did you hear about us?
(Optional) Will you be willing to recommend us?

YesMaybeNo
(Optional) Will you allow themassagenegotiator.com to contact you about promotional deals, send you your assessment and receipt to your email, text you, or call you about promotional offers? Select all that apply.

email promotional dealstext me promotional offerscall me about promotional offerssend me my assessment and suggestions for next massage service and detailed receipt
If your friend referred you to themassagenegotiator.com for massage therapy services, who is your friend?
Client's Friend's name
(Optional) Please select all the options for selecting The Massage Negotiator for your mobile massage therapy needs from the list below.

This is my first massage everThis is a gift from a loved oneI have had massages before and am too busy to visit or schedule in a massage at any of the local massage providers near meI have had a massage before but very seldom to feel like the massage is something my body needsI just want companionship and someone to listen and/or talk toI am in so much pain I cannot sleep and think massage will helpI am in so much pain from aches due to starting a new exercise routine, a new physically demanding job, or similar activitiesMy friend, family member, or close acquaintance recommended a massage to relax, because my life is so stressfulIt is my birthday and nobody thought of me or doesn't appreciate me and I want to celebrate me with a massageI am recovering from surgery and need a massage to improve healing outcomes and decrease healing timeI am changing my lifestyle for the better and want to help my health by doing regular massage in combination with my diet, exercising, stretching, sleep, lowering stress, and other wellness additions to my healthI don't want to drive to and from a massage provider but am used to regular massages
Thank you for your time filling out this form. We look forward to providing you with massage services at your scheduled massage appointment address.
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The Massage Negotiator Client Liability Form :