Body and Beauty Solutions - Massage Intake Form

The Ethereal Realm

All information is held confident. At no given point is information disclosed or shared without client’s written consent.
Date *

Month Day Year
Date
Full Name *

First Name Last Name
Birth Date *

Month Day Year
Phone Number *
E-mail *
example@example.com
How did you hear of us? *
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Health Information
Medications
Allergies
1. Areas of discomfort/pain
General Health: Check all that apply

1. Do you have any sensitivity to sound or vibration? 2. Do you have any metal implants, a pacemaker or body piercings? 3. History of Seizures 4. Heart Condition Psychiatric Disorder 5. Herpes/Shingles High Blood Pressure Low Blood Pressure 5. Numbness/Tingling Sinus Problems Allergies 6. Chronic Pain Varicose Veins 7. Blood Clots 8. Sprains/Strains 9. Diabetes Gas/Bloating 10. Headaches 11. Arthritis 12. Pregnancy ( ___ weeks) 13. Fatigue/Sleep Disorder 14. Depression/Anxiety Cancer
2. Allergies/Medications
2. Onset of discomfort/pain
6. Have you ever injured this area before?
8. List all related treatments received for this injury
9. Have you ever received therapeutic massage for a specific problem or injury?
12. Are you currently seeing any other healthcare professional?
Head Symptoms

Temples Forehead Top of head In the eyes Entire head Base of skull Dizziness Fainting Light-headedness Pain in ears Ringing in ears Other
Neck Symptoms

Stiffness Pain at neck shoulder junction Pain when turning head Pain with side to side movements Neck feels out of place Muscle spasm in neck Gliding/Grating sound with neck movement Diagnosed bone spurs Diagnosed disc herniation Other
Shoulders Symptoms

Pain in shoulder Front Back Side Pain deep in shoulder joint Diagnosed bursitis Diagnosed Arthritis Can't raise arm above shoulder level Can't raise arm over head Other
Arms & Hands Symptoms

Pain in upper arm Pain in forearm Pain in wrist Pain in fingers Sensation of pins & needles in arm Sensation of pins & needles in fingers Fingers go to sleep Hands cold Swollen joints in fingers Sore joints in fingers Diagnosed arthritis Loss of grip strength Other
Mid-Back Symptoms

Mid-back pain Pain between shoulder blades Pain up/down back Pain across mid back Pain with breathing Other
Low Back Symptoms

Low back pain Low back pain is worse when working Low back pain is worse when lifting Low back pain is worse when stooping Low back pain is worse when standing Low back pain is worse when sitting Low back pain is worse when bending Low back pain is worse when coughing Pinched nerve in low back Low back feels out of place Pain up/down low back Pain across low back Diagnosed disc herniation Other
Hip Symptoms

Pain in buttocks Pain in buttocks when standing Pain buttocks in buttocks when sitting Pain on side of hip Pain deep in hip joint Pain on sit bone Diagnosed bursitis Diagnosed arthritis Other
Legs and Feet Symptoms

Pain down RIGHT leg Pain down LEFT leg Pain down BOTH legs Leg cramps Pin & Needles in RIGHT leg Pin & Needles in LEFT leg Numbness in RIGHT leg Numbness in LEFT leg Numbness in RIGHT foot Numbness in LEFT foot Numbness in toes Feet feel cold Cramps in RIGHT foot Cramps in LEFT foot Swollen RIGHT ankle Swollen LEFT Ankle Swollen RIGHT foot Swollen LEFT foot Pain in RIGHT Foot Pain in LEFT Foot Pain in RIGHT knee Pain in LEFT knee Diagnosed Arthritis Other
Appointment Policies and Consent
CANCELLATION A credit card will now be required to schedule an appointment in office and online. A 24-hour notice is required to cancel or reschedule an appointment; failing to do so will result in 50% of the full price session being charged to the card on file. The full amount of the service scheduled will be acquired for no-show, no call clients. This policy applies to members and package holders as well; no show clients will lose their scheduled session.

There will be no exceptions to this policy. By booking your appointment with The Ethereal Realm you acknowledge that you have read, understood and agreed to the Cancellation Policy.

LATE ARRIVALS I suggest all new clients arrive 5-10 minutes prior to your appointment time; this allows time to complete any necessary paperwork, communicate your needs with your therapist, and begin on time. If you are late, you will receive only the amount remaining of your scheduled appointment. A 15-minute grace period is provided for each appointment. If your anticipated arrival time exceeds the grace period, you will be asked to reschedule. Arriving more than 15 minutes late to your appointment without notice will be considered a no-show client. If you arrive 15 minutes or later for a scheduled appointment the service provider has the right to refuse service, the massage therapist has the right to charge the client in full for paid services.

GENERAL CONDUCT All massages are for therapeutic purposes only. All clients must complete a consultation form prior to treatment and will receive a brief consultation as part of their treatment. Treatments will only be conducted if therapist deems the treatment safe for the client to receive. Immediate termination of the session will ensue if the customer engages in illicit or sexually suggestive remarks, sexual advances, drug use, excessive drinking and/or other inappropriate behavior. If the session is terminated due to the customer’s inappropriate behavior, the client will not be permitted to return. Draping is mandatory.

PRIVACY Consultations and client treatment details will not be discussed with anyone other than the client unless the client is under the age of 18 or has a care worker or guardian. Every new client must complete an intake form prior to receiving treatment. By signing the intake form, clients are giving Body and Beauty Solutions permission to hold records and data concerning the person. All intake and treatment notes will be kept securely on file. Personal information will not be shared with any third party.

MINORS Clients under 18 years of age must be accompanied by an adult. The adult must give permission for the treatment to be performed, along with signing their intake form. The adult should be present in the room throughout the treatment.

REFUNDS Refunds are not permitted for any memberships, massage packages, or other pre-paid services.

CLIENT CONSENT FOR VIBRATIONAL SOUND AND ENERGY THERAPY
I understand that Vibrational Sound Therapy is a gentle, sound based approach to health and healing that can potentially assist my body in its natural ability to heal. I fully acknowledge and understand that this is accomplished through the use of light contact and/or no contact touch. I acknowledge that long term imbalances or dis-ease in my body sometimes requires multiple sessions in order to facilitate the level of relaxation needed by the body to heal itself.

I understand that Vibrational Sound Therapy is not intended to replace any currently prescribed medical treatments as ordered by my physicians, nor any other medical care I have, or may be advised to seek by them. I understand that the practitioner will neither diagnose any medical condition, nor prescribe for any condition that I might have, nor does that practitioner make any specific claims
regarding results from the sessions that I receive. I agree that it is my responsibility to consult a licensed medical practitioner for any physical or mental complaints I may have.

I give my consent to receive Vibrational Sound Therapy.
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The Ethereal Realm

Health Information

Appointment Policies and Consent