New Massage Client Liability Consent Form

Full Name*

First NameLast Name

Birth Date *

Date

Phone Number*

Area CodePhone Number

E-mail

Emergency Contact, Relationship & Phone #

How did you hear about us?

Please read the following and sign your name after reading each item below about your massage session.

I understand that by purchasing a massage session from SALT CAVES OF ARKANSAS LLC ("EDEN SALT STUDIO") I am allowing said massage therapist to work on my body for the purchased amount of time in one of the modalities he or she is trained, educated, licensed, and insured to perform said modality service on my body. I hold any massage therapist working through EDEN SALT STUDIO free from liability for any injury that I may have due to a pre-existing condition or not having my doctor approve massage therapy on any condition not disclosed at or before the initialization of my massage session.

All laws and precautions common to the modality and my health condition as indicated below will be followed according to the state of Arkansas and the Arkansas Department of Health Massage Therapy Section standards and practices for massage therapists operating in Arkansas. Any pre-existing health conditions are to be disclosed before the massage session begins and I know that I am using massage as an alternative therapy to treat pain possibly caused by the soft tissue of my muscles, tendons, or ligaments of my body and do not expect to be treated for pain radiating from underlying ailments or previous treatments that are supervised by one of my physicians.

Only massage of those body parts uncovered and not including the genitalia, breasts, or the medial gluteal region along the sacrum (buttocks crack) will be performed. The abdomen will only be massaged if requested before the session for digestive or scar adhesion myofascial and/or lymph drainage methods, and the breasts will be covered for females as well as underwear will be worn by both genders. Draping protocols will be followed for heat sensitive patrons and only each body part worked on will be undraped and re-draped by linens when moving to the next body part, until the conclusion of the massage session.

Any illicit requests to the massage therapist at any time suggested or implied is reason enough to automatically end the massage therapy appointment with zero refund and possibly have law enforcement called if needed. Any conversation or body language that can be understood to be sexually explicit or implied towards my massage therapist, violent towards my massage therapist, offensive towards my massage therapist, or socially and reasonably considered disrespectful towards my massage therapist is reason enough to have my massage session end and pay for the service will not be refunded.

Prone (face down), supine (face up), and/or side lying massage positions may be used in the session, according to your pre-determined assessment and consultation. If I find other areas that are in pain, ache, tender, and/or need more or less time or pressure focusing on that area as it is encountered, I will notify the massage therapist at that time so that my massage session maximizes my expectations for this service. I understand my massage therapist might not be able to intuitively know when I want more pressure when my muscles spasm or contract with more or less pressure as some clients want less pressure to reduce pain and others want to endure it to fix underlying muscle aches.

I understand each client is unique in their associated pain, sensitivity, and patterns of aches and tension and do not expect my massage therapist to know exactly how I want these conditions addressed without me verbally explaining that I want more pressure, less pressure, some stretching, some heat, some cold, and so on applied to that area of my body.

I understand it is always important to maintain proper hydration levels during massage therapy. We highly recommend drinking a minimum of 4 oz. of water prior to your session and a minimum of 8 oz. of water after your massage.

I FURTHER UNDERSTAND THAT IT IS MY RESPONSIBILITY TO REQUEST, COMPLETE AND UPDATE A NEW INTAKE FORM ON MY FUTURE VISITS TO EDEN SALT STUDIO" IF I EXPERIENCE A CHANGE TO MY CURRENT HEALTH CONDITIONS LISTED/DESCRIBED ABOVE. I UNDERSTAND AND VOLUNTARILY ACCEPT THE RISKS ASSOCIATED WITH THE MASSAGE THERAPY SERVICES.

Do you have any allergies/sensitivities to lotion or oils?

YesNo

Please briefly describe the reason you want a 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.

Select the TYPE OF PRESSURE you want used most of your massage session.

Lightmediumdeep tissuesuper deep tissue

(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)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)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)

(Optional) What areas of your body do you want massage to be FOCUSED?

upper body, neck, shoulders, arms, hands, scalp, and facelower body, glutes, hips, legs, knees, ankles, and feethands and feetlower backglutes, hips, and lower backcalves, hamstrings, quads, and glutesscalp, face, neck, and shouldersOther

Annotate Image by drawing or typing in the areas you feel pain so your massage therapist will know how to customize your massage session. At no time will the genitals, breasts, or midline of the gluteus be massaged nor should any client touch themselves in those areas while in the presence of the massage therapist.

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 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

Please Sign and Date this form confirming you agree to the above statements.*

Date*

Date

Thank you for taking time to fill out this form. Have a wonderful day and we look forward to accomplishing your massage goals with you in the future.

Massage Therapy Intake & Liability Consent Form