New Massage Client Liability Consent Form after May 15, 2021

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 Name Last Name
Birth Date *

Month Day Year
Date
Please provide your service address if this is for mobile massage therapy services. *

Street Address

Street Address Line 2

City State

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 Code Phone 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
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 $10/30 minutes fee added to the service or $1/minute.

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 $20 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. 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 and 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.

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. You receive a discount of $10 per massage if not in a bundled or packaged massage promotion for filling out the Health intake form for each client before the massage starts for each client. If this is a public event or family massage it doesn't apply.

16. 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.
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. *

Month Day Year
Date
Please select all the options for selecting The Massage Negotiator for your mobile massage therapy needs from the list below. A score calculation will be assessed and determine if you are a preferred client. *

This is my first massage ever This is a gift from a loved one I have had massages before and am too busy to visit or schedule in a massage at any of the local massage providers near me I have had a massage before but very seldom to feel like the massage is something my body needs I just want companionship and someone to listen and/or talk to I am in so much pain I cannot sleep and think massage will help I am in so much pain from aches due to starting a new exercise routine, a new physically demanding job, or similar activities I want a massage because I hate females and want to make her feel submissive to my needs and disrespect her by treating her like how I was treated badly before as revenge to all females My friend, family member, or close acquaintance recommended a massage to relax, because my life is so stressful It is my birthday and nobody thought of me or doesn't appreciate me and I want to celebrate me with a massage I am recovering from surgery and need a massage to improve healing outcomes and decrease healing time I 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 health I don't want to drive to and from a massage provider but am used to regular massages
Calculation
Do you prefer a female or male massage therapist or no preference?

female massage therapist male massage therapist No preference undecided
Do you prefer lotion or oil?

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

male female gender fluid (male same days/female some days/no preference on identity, gender neutral)
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. If you are a male gender, please assert below how you will make our female massage therapists feel comfortable around you by stating some reasons you are not a male who talks down to a female, cracks jokes that undermine a female person's credibility, or classify females into 2-4 categories for (good/bad or mom/wife/bitch/ho). Thank you for taking the time to do this.
Please select the following health conditions you have

High or Low Blood Pressure Diabetes Kidney disease Cancer Spinal injuries amputated limb missing organ (i.e. left lung, kidney) recent abdominal surgery (post natal, tummy tuck, hysterectomy, etc.) Rheumatoid Arthritis Osteoporosis Leukemia Use Blood Thinners Migraines Recent Surgeries (limbs, neck, low back, shoulders, etc.) Skin Abrasions Bruise easily Plantar Fasciitis Fibromyalgia Ticklish feet or other areas of body Cold hands and feet Irritable Bowel Syndrom (IBS)

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 need more pressure)
(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) 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) Full spectrum CBD (.oo3 THC) TOPICAL (must be 18 or older)
(Optional) Which areas do you want AVOIDED?

hair face feet glutial muscles lower back upper arms forearms elbows calves hamstrings (back of legs) quadriceps (front thighs) hands neck knees pectoralis major (chest) abdomen (digestion/lymph drainage)
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 Tool palms 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 Stones Cold Stones Chinese Cups Integrative Assisted Soft Tissue Mobilization (IASTM) tools Full Spectrum CBD oil Open to trying anything that works sound therapy
(Optional) What are your massage goals? In other words, what do you expect to accomplish during your massage session?

increased range of motion relaxed state of mind less to no pain in areas of my body that ache less fluid build up in areas of my body that have edema less pain related to fibromyalgia less inflammation from stress Sleep better less tension less anxiety
(Optional) Which additional services would you like to add to your massage session?

aromatherapy hot stone massage cold stone massage variable speed massage for lymph drainage variable speed massage for sports massage localized pain relief instrument assisted soft tissue (IASTM) tool, stainless steel or gua sha tool gua sha rose quarts tools for face massage and aiding in draining lymph from face CBD oil/balm for immunity boost and pain relief kinesiology taping with sports balm/gel for pain relief Dynamic cupping for lymph drainage, myofascial massage, and/or promoting immunity and recovery Infrared light therapy for arthritis pain relief Radiofrequency 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 $145) family massage special (5 hours of massage for as many family members to split time between for $180) manual lymphatic drainage (ten 1-hour sessions $45 each, $450 prepaid) monthly membership (four 1-hour massage sessions per month, $200)
Please select a day of the week that works best for you and or your family/friends schedule for receiving your bundled massage services package from the drop-down list below.
What hours on the day selected above work best for you and your family/friends?

9 am - 12 pm 4 pm - 9 pm
(Optional) How did you hear about us?
(Optional) Will you be willing to recommend us?

Yes Maybe No
(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 deals text me promotional offers call me about promotional offers send 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
Thank you for your time filling out this form. We look forward to providing you with massage services at your scheduled massage appointment address.
Should be Empty:

The Massage Negotiator Client Liability Form :