Massage Intake Form

Want Massage Individual Outcall Intake

Please fill in the form below
Emalene Lake Licensed Massage Therapist

256 W 300 N Kanab, UT 84741 and 10 W 100 S Orderville, UT 84758 Ph:801.358.4656 Email:wantmassage1@gmail.com Web:wantmassage.com
MINIMUM OF TWO (2) PEOPLE FOR OUTCALL. $30 OUTCALL FEE APPLIED PER TRIP/PER THERAPIST.
If there are any costs/fees associated with the location the client has chosen for their booking, you, the client, will be responsible for those fees. The Massage Therapist will not guarantee or arrange payment on any location. $30 Travel fee covers travel within 30 minutes/miles of Orderville, UT. Any location outside of these limits will be subject to an additional charge of $1.00/minute-mile as part of the agreement. If more than 1 therapist is needed the travel fee will be per therapist.
Name*

First NameLast Name
E-mail*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Contact Phone Number*

Area CodePhone Number
Is this a cell number?*
Date of Birth*

MonthDayYear
Location you scheduled*
How did you hear about me or who recommended you see me? Referred by: Google, Friend, Family
In case of emergency...
Emergency Contact:*

First NameLast Name
Relationship*
Contact Number*

Area CodePhone Number
Reason for Massage*
Have you ever experienced a professional massage? How recently?*
2 part question Yes/No and How recent
Do you frequently suffer from stress*

NoYes Work RelatedYes Daily Life RelatedYes Work & Daily Life RelatedOther
Do you have diabetes?*

YesNo
Do you suffer from Arthritis or Osteoporosis?*

YesNo
Are you pregnant?*

YesNo
Do you have high blood pressure?*

YesNo
Taking any medications, currently?*

YesNo
If yes to taking medications, please list here
Have you been in an accident or injured in the past two years?*

YesNo
If yes, please explain injuries.
Broke xyz, Surgery on xyz, Whiplash etc
Do you sit at a computer daily?*

YesNo
How many hours?
Do you bruise easily? Light pressure causes bruising. Not finding furniture in the dark with your body kind of bruising.*

YesNo
Are you Sensitive to touch or pressure in any area? If area touched you will literally levitate off the table while speaking in tongues.*

YesNoDepends on the day
If Sensitive to touch or Pressure, please list areas here.
Spot in middle of back, Legs, Feet, etc
Are there any areas you would rather not have worked?*

YesNo
If there are areas you don't want worked, please list it here
Glutes, Feet, Neck etc
Do you have tension or soreness in a specific area?*
Specify Area
Do you have numbness or stabbing pain in a specific area?*
Specify Area
Do you have any other medical conditions or other concerns you want me to know about or discuss?

SERVICES If paying with credit card select services below. Otherwise leave ALL boxes blank.

OUTCALL 60m Swedish Massage$125.00

Basic full body massage done in an outcall setting. Area must accommodate table & therapist. Minimum required for 1 table is 10'x 8'

OUTCALL 30m Swedish Massage$85.00

Focused area massage done in an outcall setting: Neck/Back muscles, Arms/Hands or Legs/Feet. Area must accommodate table & therapist. Minimum required for 1 table is 10'x 8'

OUTCALL 60m Reiki$125.00

Reiki is a Japanese technique for stress reduction and relaxation that also promotes healing. It is administered by "laying on hands" light pressure that helps balance and restore the unseen "life force energy" (Meridians/Chakras/Energy Pathways). If one's "life force energy" is low, then we are more likely to get sick or feel stress, and if it is high, we are more capable of being happy and healthy. This also helps with emotional issues.

OUTCALL 60m Lymphatic Drainage Massage$125.00

Lymphatic drainage massage is a form of gentle, rhythmic movement that encourages the movement of lymph fluids around the body. The lymph is just under the skin. The fluid in the lymphatic system helps remove waste and toxins from the bodily tissues. Lymphatic drainage massage can benefit people who are experiencing the following: lymphedema, fibromyalgia, swelling or edema, non-infectious skin disorders, fatigue, insomnia, stress, digestive problems, arthritis, migraine episodes, post surgical edema.

OUTCALL 60m Cranial Sacral$125.00

CranioSacral Therapy (CST) is a gentle, hands-on approach that releases tensions deep in the body to relieve pain and dysfunction and improve whole-body health and performance. It was pioneered and developed by Osteopathic Physician John E. Upledger after years of clinical testing and research at Michigan State University where he served as professor of biomechanics. Using a soft touch which is generally no greater than 5 grams - about the weight of a nickel - practitioners release restrictions in the soft tissues that surround the central nervous system. CST is increasingly used as a preventive health measure for its ability to bolster resistance to disease, and it's effective for a wide range of medical problems associated with pain and dysfunction.

Gratuity$20.00

If you would like to add gratuity please select option below. Thank you.

Item subtotal:$0.00

Total $0.00

Credit Card

If your group coordinator is not paying for entire group, or you are NOT paying with credit card above, please select payment method here. And put date of service and location in the memo line.

	Paying Venmo @emalene-lake (last four # are 4656)	Paying PayPal @emmlake	Paying Cash Day Of Service
60 Min Massage/Service $125
30 Min Massage/Service $85

General & Medical Information Please take a moment to carefully read the following information and sign where indicated. If you have a specific medical condition or specific symptoms, bodywork may be contraindicated. You, the Client understand that the bodywork You receive is provided for the basic purpose of relaxation and relief of muscular tension. If You experience any pain or discomfort during this session, You will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to Your level of comfort. You understand that bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that You should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailment that You are aware of. You understand that bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, 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 bodywork should not be performed under certain medical conditions, You affirm that You have stated all known medical conditions, and answered all questions honestly.

Cancelation Policy
I require 24 hours notice of appointment cancellation. If this isn't given the full appointment cost will be charged.

Inappropriate Behavior by the Client
You, the Client, understand that any inappropriate, illicit or sexually suggestive remarks, advances or behavior made by You in a session, outside the office in email, text or verbally, will result in immediate termination of the current session or future scheduled sessions. You, will be liable for full payment of the scheduled appointments, currently in session or future scheduled. You, will be refused service for any future appointments and criminal charges may be filed against You, the Client, by the Practitioner.
I, the Client, 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 also understand that any inappropriate, illicit or sexually suggestive remarks, advances or behavior made by me, The Client, in a session or outside the office in email, text or verbally, will result in immediate termination of the current session or future scheduled sessions and I, The Client, will be liable for full payment of all the scheduled appointments and criminal charges may be filed against me by the Practitioner. By signing below I, the Client, accept and acknowledge the conditions set above. *

Clear
COVID-19 information: MASK NOT REQUIRED. COVID LIABILITY RELEASE, RELEASE OF LIABILITY AND AGREEMENT NOT TO SUE, INDEMNIFICATION, HOLD HARMLESS, LIMITATION OF WARRANTY. In consideration for providing massage and spa services, by signing below you agree to accept all responsibility for the risk that you may contract COVID-19. While we are taking client safety and the safety of our staff very serious, by sanitation and scheduling procedures, we cannot guarantee that any of these measures will completely protect you from contracting COVID-19. I agree that if I take any steps to make a claim for damages against WANT MASSAGE/EMALENE LAKE, its agents, contractors, employees or any other released parties arising out of my receipt of massage services during my visit, I shall be obligated to pay all attorney's fees and costs incurred as a result of such claim. I acknowledge that I can go elsewhere to have massage services and I acknowledge that WANT MASSAGE/EMALENE LAKE is not the only establishment where I can obtain massage. By signing this agreement, I acknowledge that I am free to go to other massage businesses who may not require my agreement to accept responsibility for contracting COVID-19 and I chose to have a massage or spa services. 👍Please do not sneeze on the therapist, lick the door knobs or light switches and remember to wash your hands after using the bathroom or petting animals😉 WANT MASSAGE/EMALENE LAKE RESERVES THE RIGHT TO TURN AWAY ANYONE THAT VISIBLY PRESENTS SYMPTOMS OF COVID OR OTHER ILLNESS THAT MAY AFFECT THE MASSAGE THERAPIST. *

Clear
Date of agreement*

MonthDayYear
Should be Empty:

Want Massage Individual Outcall Intake

Emalene Lake Licensed Massage Therapist

Credit Card