Steven Townsend, LMT: Massage Therapy Consultation Form

Steven Townsend, LMT - Massage Therapy Consultation Form
Steven Townsend, LMT | Massage for Humans

Caddo Office Reimagined

6401 Eldorado Pkwy Suite 320, McKinney, TX 75070

2060 N. Collins Blvd Suite 109, Richardson, TX, 75080

www.StevenTownsendMassage.com | StevenTownsendLMT@gmail.com

972-365-3820 (call or text)
Name*

First Name Last Name
Gender*
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Email*
Your Birthday*

MonthDay Year
Address*

Street Address

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Occupation / Company
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How often do you like to receive a massage therapy?
What is more important to you?
The parts of the body to be massaged are what is called “whole body” this includes feet, legs, abdominal area, pectorals, arms, hands, shoulders, neck, face, scalp, gluteals and back.
Please list areas of the body you would like focused therapy on
Please list areas of the body you want avoided
Medical History: List all medical conditions including injuries and surgeries
Are you currently pregnant?
Please list any Car Accidents
Please List any Sexual Transmitted Diseases
Do you currently have Cancer? (if yes please explain)
Level of Exercise:

High - Hard, Breaking a sweat after 3-5 minutes. Breathing is deep and rapid. High Intensity.Moderate - Somewhat Hard, Breaking a sweat after 10 minutes, breathing becomes deeper and more frequent.Light - Easy, Does not induce sweating no change in breathing.
Please list any vitamins/supplements or prescription medications you are currently taking

Massage is for the sole purpose of stress reduction, relief from muscle tension, muscle spasms and to increase circulation. Massage Therapists do not diagnose or prescribe, nor is massage a substitute for medical examination of a person's physical or mental health. Please consult a physician for any medical concerns.

If my health history or any of the information on this form changes or the reason for receiving massage changes, you must update me with a new consultation form before your next treatment.

Your feedback is essential to provide you with the best massage experience possible. If you or your therapist becomes uncomfortable for any reason during the massage session either person can request the massage to end.

Your therapist uses a draping method that includes: Covering the body with a sheet or towel, only uncovering the part of the body being massaged. Draping of the genital area and gluteal cleavage will be used at all times during the session for all clients.

Massage can Not be provided if you have a contagious virus, Flu or Cold, Cancer, if you are under the influence of Alcohol or illegal Drugs, a contagious or spreadable disease, and poison ivy or poison oak. It's also not uncommon to have some soreness or even bruising after a therapeutic massage session.
Fragrance-Free Policy: I ask for all clients to refrain from wearing strong perfume, cologne, after-shave, scented lotions, body sprays or other similar products and smoking right befoe your treatment on the day you vist.
Sickness Policy: I kindly ask that you reschedule your appointment as soon as you are aware of an infectious or contagious condition. If you arrive for your appointment with symptoms of an illness, you will kindly be asked to reschedule your appointment to avoid the spread of germs or make your condition worse.
Special Consent for Massage of the Breast/Chest Region:

Your therapist shall drape the breasts of all female clients and not engage in breast massage of female clients unless you the client gives signed consent before each session involving breast massage.

In order to achieve individual treatment goals, your therapist may deem it appropriate to work on muscles or connective tissue within breast/chest region. Treatment of certain conditions of the breast/chest, rib cage, chest muscles and back issues will be most effective when it is preceded by the relaxation of surrounding muscles. This includes the pectoralis major, pectoralis minor, intercostal muscles, and scar tissue. Please let your therapist know immediately if at any time treatment feels uncomfortable in any way.
Consent for Massage of Chest Region*
Cancellation Policy: 24 Hour notice.
Informed Consent

By typing my first name, last name, and providing my e-signature below, I am indicating the following:

1. I have read and fully understand all questions and information provided in this Massage Therapy Consultation Form in its entirety.

2. I have completed the Massage Therapy Consultation Form accurately and to the best of my knowledge.
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Steven Townsend, LMT - Massage Therapy Consultation Form