Massage Intake Form

Neblibana

Massage Service Intake Form
Client's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
If minor, Parent/Guardian Name is required

Parent’s First NameParent’s Last Name
Phone Number*

Area CodePhone Number
Email Address
example@example.com
Address

Street Address

Apartment or Suite Number

CityState

Zip Code
Occupation
Emergency Contact

First NameLast Name
Emergency Contact's Phone Number

Area CodePhone Number
Medical Conditions
Are you under the care of a physician?*

YesNo
Please select if you have experienced or are experiencing the following conditions:

CancerHypotensionMetal ImplantsHypertensionPacemaker or DefibrillatorDiabetesClaustrophobiaHeart DiseaseThyroid DisorderHysterectomyHormonal ImbalanceEpilepsy or SeizuresBlush EasilyHIV/AIDSHepatitis A/B/CMigraines/HeadachesDepression/AnxietyPsoriasisRosaceaEczemaBruise EasilySpinal Cord InjuryImmune DisorderLupusKeloid ScarringBlood Clot DisorderSkin DiseaseFibromyalgiaMenopauseCirculation DisorderVaricose VeinsOther
Any known allergies?

ShellfishIodineAspirinTree NutsSunscreenLatexFragranceEssential OilsDairyPollenNoneOther
List any medications or supplements you’re taking:
What are your goals for today's session?
Female Clients
Are you taking birth control?

YesNo
Are you pregnant or breastfeeding?

YesNo
Treatment Policies
- Client services and chart information are confidential. Written authorization is required from you to release any information.
- Your scheduled session is set aside for you. We do not double book appointments.
- Please reschedule your session if you are more than 15 minutes late.
- All treatments, services and products are non-refundable. Rescheduling requests should be made at least 24-hours prior to your scheduled appointment time. Booking/retainer fee of 50% of the service price is due at the initial booking, is non-refundable, and will go towards the balance of your services. Remaining balance will be due once services are provided. Please call at least 48-hours prior to your appointment should you need to cancel to avoid the booking/retainer fee, 50% of the listed menu price.
- 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.
- After your therapist has left the room, you may disrobe to your comfort level.
- Client understands that the therapist or they may end the session at any time for any reason.
- Inappropriate behavior is not tolerated and may be prosecuted to the full extent of the law.
- Right to Refuse Service: The licensed professionals at Neblibana reserve the right to refuse services at their discretion and dismiss disruptive and/or abusive clients when necessary.
Client Agreement
I understand that my data will be strictly confidential. Neblibana LLC does not sell, share, or resell information.

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

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

I acknowledge that this treatment is strictly elective, and no medical claims have been expressed or implied.

I understand that if I hold some important information and/or complications that may pose a threat to my health and/or physical well-being happen, Neblibana LLC and its licensed massage therapist will not be liable.

By my electronic signature below, I agree to the massage treatment policies and client agreement above.
Client Signature*

Clear
If minor, Parent/Guardian signature is required

Clear
Date Signed*

MonthDayYear
Date
How did you find out about us?

FacebookGoogle SearchInstagramOther
Newsletter

Yes, subscribe me to this newsletter.
Should be Empty:

Neblibana

Medical Conditions

Female Clients

Treatment Policies

Client Agreement