• Massage Client Intake Form

    Please give accurate and honest health information for your and everyone's safety.
  •  -

  •  -  -
    Pick a Date
  • Massage Policies:

    Client 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. We do not double book appointments

           • Please reschedule your session if you are more than 15 minutes late

           • 24 hour cancellation notice is required to avoid the charge of the full price of your session

           • You will be draped and at no time will genitalia or breast tissue be exposed

           • 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

           • Inappropriate behavior will not be tolerated and may be prosecuted to the full extent of the law and client will be responsible for payment of full session.

     

    Client Agreement:

    I understand that 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 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 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 harmless Flawless Spa Retreat of Distinction and my massage therapists 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. 

  • Clear
  •  -  -
    Pick a Date
  • For Office Use Only

    To be updated internally by the staff.
  •  -  -
    Pick a Date
  •  -  -
    Pick a Date
  •  -  -
    Pick a Date
  •  -  -
    Pick a Date
  •  -  -
    Pick a Date
  •  -  -
    Pick a Date
  •  -  -
    Pick a Date
  •  -  -
    Pick a Date
  •  -  -
    Pick a Date
  •  -  -
    Pick a Date
  •  -  -
    Pick a Date
  • Should be Empty: