Earth N Soul's Massage Intake Form

Client Intake Form All information is held strictest confidence. At no given point is information disclosed or shared without client’s written consent.

You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose.

Full Name*

First NameMiddle Name

Appointment date*

Date

Birth Date*

DayMonthYear

Gender*

MaleFemaleOther

Height/Weigh (LB, KB)*

Address

Street Address

Street Address Line 2

State

Zip CodeCountry

How do you know about us?*

E-mail*

Phone Number*

Occupation*

Allergies*

Female Only Are you pregnant?

YesNo

History of Pathology

1. List Areas of Discomfort or Pain*

5. Have you ever been in an accident (automobile, work, falls, etc.) ?*

Answer: Y/N (If yes, please describe)

2. Rate of Pain Today or Recently*

The level of massage pressure

Level 1: Light pressure relaxing massage (Aromatherapy)Level 2: Medium pressure massage with no specific trigger point work (Swedish, Combination massage)Level 2+ : Can go deep with some trigger point work (Combination)Level 3: Medium to deep pressure massage with trigger point work (Thai, Combination, Deep tissue)Level 4: Very deep massage with trigger point (Thai, Deep tissue, Combination,Trigger Point)Therapist recommendOther

Massage Policies: Clients are require to answer the Covid-19 questions as a condition of entry building. Masks are recommended at all times regardless of vaccination status except when eating, drinking, or alone in an enclosed room. services and chart information are confidential. Written authorization is required from you to release any information.

Please turn off your cell phone for optimal relaxation.
Your scheduled session is set aside for you.
Please contact your provider if you are going to be late. 15 Minute late may subject late fee or reduce the time of treatments.
12 hours cancellation notice is required to avoid being charged for your session.
You will have a consultation with your therapist to discuss your session.
Should the session require, after your therapist has left the room, you may disrobe to your comfort level.
I understand that my therapeutic massage therapist or I may end the session at any time for any reason.
Client read and understand term and condition on Phuket Deluxe Spa
Inappropriate behavior will not be tolerated and may be prosecuted to the full extent of the law.
Client Agreement: I understand that 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 understand that treatment given is designed to address the care and prevention of myofascial pain and dysfunction. I also undersand 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 understand that my failure to do so may post a threat to my health and/physical well being and I hold Phuket Deluxe Spa and my therapeutic massage therapist from any liability whatsoever arising from failure on my part. By my electronic signature below, I agree to the massage policy and client agreement above.

Signature*

Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.