Massage Consent Form

Massage Intake Form

Please complete before appointment
Name
Date

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
Address

Address

Street Address Line 2

City/State/ZipState / Province

Postal / Zip Code
Phone (day)
Format: (000) 000-0000.
Occupation
Email
example@example.com
Primary Physician
Phone
Format: (000) 000-0000.
Emergency Contact
Relationship
Phone
Format: (000) 000-0000.
How did you hear about us?
Medical Information
Are you taking any medications?
If yes, please list name and use
Are you currently pregnant?
If yes, how far along?
Any high risk factors?
Do you suffer from chronic pain?
If yes, please explain
What makes it better?
What makes it worse?
Have you had any surgeries in the past 12
If yes, please list
Mark any that apply
Explain any conditions you have marked above
Have you been diagnosed with cancer?
When were you first diagnosed?
What type of cancer?
Where was/is located?
Are you being treated now?
Is Cancer currently active?
When was the your last treatment?
Massage Information
Have you had a professional massage before?
What type of massage are you seeking?
Please explain
Cupping informed consent

Cupping is an ancient technique; the purpose of this technique is to promote health and healing by: losing soft tissue and connective tissue, scarring an adhesions moving stagnation and increasing lympathic flow and circulation. This therapy utilizes cups and a vacuum pistol to create suction on the body surface.

Potential reactions are temporary and may include:

Discoloration due to toxins and old blood being brought to the surface.

Post tenderness, usually less than experience from deep tissue work.

Redness and itching: increasing vast-dilation and/or inflammation brought to the surface.

Decreased blood pressure: due to vast-dilation and/or nervous system sedation.

After care recommendations:

Drink plenty of water to help elimate toxins out of the body.

Avoid showers, steam, sauna and exercise immediately following bodywork.

Light stretching and range of motion excercises are beneficial.

Exercise the next day will help increase circulation to aid in daring of cup kisses.

Contraindications:

People who are on blood thinners should not experience Cupping. If you start taking such medication please inform the therapist so your treatment plan can be adjusted.

Agreement:

If I choose to experience this therapy in my treatment, I understand the effects and after-care recommendations. It has been explained to me that there is possibility of temporary skin discoloration or "cup kiss" appearing as tissue is released. I am aware that a "cup kiss" is NOT a bruise and that it wil dissipate within a few hours to a few days.
I understand and agree

First NameLast Name
What pressure do you prefer?
Do you have any allergies or sensitivities?
Please explain
Are there any areas (feet,face, abdomen, etc.) you DO NOT want massaged?
Please explain
What are your goals for this treatment session? Note areas of discomfort or focus.
Notes
Informed Consent

Please read and sign
Lateness and Cancellation Policy
Our time is very valuable. To ensure we can provide all our clients with excellent service, we ask that you be on time to all your appointments. Please arrive at least 5 minutes prior to your scheduled time to ensure you receive your full appointment time. Please wait in the hallway if we are finishing up with another client.

In the event that you shoul be tardy, please be aware that if you are 15 minutes or more late to your appointment, you will be cancelled and charged 50% of service. You will need to reschedule, no exceptions.

In the event that you need to cancel or reschedule your appointment, we asked that you notify us at least 48 hours in advance of your scheduled appointment.

*We reserve the right to charge 50% of the scheduled service price when cancelling or rescheduling less than 48 hours prior to your appointment.

A CARD ON FILE IS REQUIRED TO BOOK ANY SERVICE.

The satisfaction of our clients is our main priority. We offer prompt solutions to any problems or concerns that may occur. We DO NOT offer refunds, credits, or exchanges for products sold or services rendered.

If, for any reason, you feel dissatisfied with any of our services, please bring this to our attention. We appreciate feedback, negative or positive, from our clients to better serve you.
The above information is accurate to the best of my knowledge and I freely give my permission to be massaged. I agree to inform the therapist of any experience of pain during the session. I understand this does not defer me from seeking medical treatment for medical conditions.

I understand that no inappropriate comments or conduct will be tolerated. Any indication of such behavior will automatically end the session and will be 100% charged to account of file.

I agree to update the massage therapist in regard to changes in my health and understand that there shall be no liability on the therapist's part should I forget to do so. I agree to hold harmless the establishment, all management, including volunteers, from and against any and all claims.

Our time together is valuable and I agree to cancel, if need be, 24 hours in advance of my appointment session. If I miss an appointment or fail to cancel within the 24 hour period, I agree to pay 50% of the full amount. If necessary, I may be required to prepay with a valid form of payment to secure my appointment.

By signing below, you agree to the following.

I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time.
Name

First NameLast Name
Client Signature
Date

MonthDayYear
Date
Parent or guardian
Parent or guardian Signature
Should be Empty:

Massage Intake Form

Medical Information

Massage Information

Cupping informed consent

Informed Consent