First Name
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Last Name
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Phone
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Date of Birth
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Address
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City
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State
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ZIP
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E-mail
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Gender
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Male
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Referred by:
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Flyer
Another client
Small street signs
Chiropractor
Physical Therapist
Local Event
Facebook
Radio
Newspaper
Internet
Yellow Pages
If another client or chiropractor referred you, please put their name
Your Occupation
In case of Emergency (Name and Contact Number)
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Have you ever experienced a professional massage or bodywork session?
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Yes
No
If yes, how recently?
What are your massage or bodywork goals?
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What kind of pressure do you prefer?
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Light
Medium
Firm
Deep
Please check the box next to the items that apply to you:
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High Stress
Diabetes
Frequent Headaches
Pregnant
Arthritis
Wear Contact Lenses
Wear Dentures
High Blood Pressure
Epilepsy / seizures
Joint Swelling
Varicose Veins
Contagious Diseases
Osteoporosis
Allergies
Bruise Easily
Broken Bones in the past 2 years
Injuries in the past two years
Cardiac or Circulatory problems
Back pain
Numbness
Stabbing pain
Sensitive to touch or pressure in any area
Pacemaker
Metal in your body from any type of surgery
None of these apply to me
Do you have tension or soreness in a specific area?
Have you ever had surgery? If so, please list off what types, location on your body, year it took place.
Other medical conditions, or are you taking any medications I should know about?
Please indicate areas that need focus.
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Please indicate areas to be avoided.
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Please indicate areas that are ticklish.
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I understand that the massage/bodywork I received is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or techniques may be adjusted to my level of comfort. I further understand that massage or bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialists for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnoses, prescribe, or treat any physical or mental illness and that nothing said in the course of the session given should be construed as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner's part should I fail to do so. I understand that the practitioner may end the massage session if the practitioner feels uncomfortable for any reason. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.
Consent to Treatment of Minor
By submitting this form, I hereby authorize the practitioner to administer massage, bodywork, or somatic therapy techniques to my child or dependent as they deem necessary.
Name of Parent/Guardian (if consenting for a minor)
Please click the submit button below after reviewing the following information.
The therapist will review your health and medical information. They will discuss the type of massage therapy services or techniques the therapist anticipates using during your session. They will described the body parts that will be massaged. Standard draping will be used during the session unless otherwise agreed to by both the client and the therapist. You can stop the massage at any point in time for any reason. Breast massage is not performed without written consent.
Late/Cancellation Policy
Please arrive at least 5 minutes* before your scheduled appointment time in order to ensure a full massage session. * If you are a new client, then you will need to arrive 5-10 minutes early to go over paperwork. Clients arriving late will receive the rest of their appointment time and will be charged for the full scheduled appointment time. Clients arriving more than 15 minutes late will be rescheduled. You may cancel your appointment without charge 24 hours before your appointment. Cancellations less than 24 hours before session will be charged 25% of the scheduled service; less than 12 hours will be charged 50%. • If you do not call to cancel your appointment or do not show up for your scheduled appointment, you will be charged 100% for the scheduled service.
Sick Policy
Both therapists and clients are vulnerable to infection from contagious illnesses. If you come in sick, it can worsen your condition. Please reschedule your appointment if you are feeling unwell. Clients with any of the following illness, or any other contagious illness not listed, will be rescheduled: Vomiting, fever, cold, influenza, diarrhea, measles, mumps, rubella, chicken pox, head lice, scabies, impetigo, meningitis, conjunctivitis, hepatitis A, thrush, polio, ringworm of the body, feet or scalp, meningococcal disease, and whooping cough.
Confirm below that you acknowledge the policies above
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I acknowledge and have full understanding of the policies.
I understand that all treatments at this facility are therapeutic is nature. I agree to communicate to the therapist any physical discomfort or draping issues during the session.
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I agree
I understand the building that Beni Massage and Wellness is located in a building that locks automatically in the evenings and on the weekends. I will wait for the therapist to open the door for me and will not leave before my appointment time. I recognize if I leave before my appointment time that I will be charged a no show fee. Beni Massage and Wellness is located in a 2 story red brick building with green awning in front of the Megaton Brewery.
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I agree
An individual who wishes to file a complaint against a massage therapist, a massage therapy school, a massage therapy instructor, or a massage therapy establishment may write to:
Complaints Management and Investigation Section P.O. Box 141369 Austin, Texas 78714-1369.Call 1-800-942-5540 to request the appropriate form or obtain more information
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Cupping Therapy Information
Cupping therapy is a negative pressure therapy using suction with a cup. It's main purpose is to relax muscle tissue, reduce inflammation and increase blood flow to the area to promote healing and healthy tissue.
We offer a free cupping therapy demonstration with Elite sessions. You can experience this on your first visit, 10th or 100th. There is no pressure for you to try this amazing therapy. It's available whenever you are ready to experience it. :)
My interest level in receiving cupping therapy today is
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Heck yes!!
Yes but at a future session
Maybe
No way!
I understand that there is the possibility of discolorations that can occur from the release and clearing of stagnation and toxins from my body.
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I agree
I also understand that this reaction is not bruising, but due to cellular debris, pathogenic factors and toxins being drawn to the surface to be cleared away by my circulatory system.
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I agree
I further understand that the discolorations will dissipate from a few hours to as long as 2 weeks in some cases and in relation to my after-care activities.
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I agree
I understand that cupping therapy modalities should not be combined with aggressive exfoliation, 4 hrs. after shaving, after sunburn or when I'm hungry or thirsty.
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I agree
I understand that I should avoid exposure to extreme cold, wet, and/or windy weather conditions, hot showers, baths, saunas, hot tubs and aggressive exercise for 24 hours. It has been explained to me that exposure to such extremes can produce undesirable effects and I should avoid such situations.
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I agree
I understand that I should avoid caffeine, alcohol, sugary food and drinks, dairy and processed meats and I should consume an abundance of clean water.
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I agree
Information has been provided to me about Cupping Therapy. If I choose to experience these therapies during treatments, I understand the potential effects and after-care recommendations.
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I agree
I understand that there are contraindications for Cupping Therapy. I have fully disclosed all health factors to my therapist, including those not mentioned on my Health History Intake Form, to avoid any complications.
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I agree
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