New Massage Client Liability Consent Form after May 15, 2021

Full Name *

First Name Last Name

Birth Date *

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 conditions and sign your name after reading each item below about your massage session.

Do you agree to the above terms and descriptions 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. *

Date

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

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.

Please select the following health conditions you have

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 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?

(Optional) Which areas do you want AVOIDED?

Annotate the image below. To indicate areas to avoid, draw an 'X' on the area of the body below. To indicate areas to focus most of the massage time, circle the area on the body below. To indicate only spend the time on these areas, draw an '*' or asterick on the area(s) on the body below.

(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.

(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?

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

The Massage Negotiator Client Liability Form :