Massage Intake Form

Massage Intake Form
Personal Information
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DOB

MonthDayYear
Date
Robe Size*
Occupation
Employer
Email*
example@example.com
Primary Physician
Emergency Contact*
Emergency Contact's Phone Number*
Relationship
How did you hear about us?*
Medical Information
Are you taking any medications?*

YesNo
If yes, please list name and use:
Are you currently pregnant?*

YesNo
If yes, how far along?
Any high risk factors?
Do you suffer from chronic pain?

YesNo
If yes, please explain
What makes it better?
What makes it worse?
Have you had any recent injuries?

YesNo
Please indicate any of the following that apply to you.*

CancerHeadaches/MigrainesArthritisDiabetesJoint Replacement(s)High/Low Blood PressureNeuropathyFibromyalgiaStrokeHeart AttackKidney DysfunctionBlood ClotsNumbnessSprains or StrainsNone of the above
Explain any conditions you have marked above:
Have you had a professional massage before?*

YesNo
What type of massage do you prefer?

RelaxationFirm PressureDeep Tissue (Upgrade Option at an additional $25 Fee)
Other
What pressure do you prefer?

LightMediumDeep
Do you have any allergies or sensitivities?

YesNo
Please explain
Are there any areas (feet, face, abdomen,etc.) you do not want massaged?*

YesNo
Please explain
Is there anything additional we should know before you receive your spa service?
Are there any areas you want to focus on?
I understand the licensed therapist shall drape the breasts of all female clients and not engage in breast massage of female clients unless the client gives written consent before each session involving breast massage.

Draping of the genital area and gluteal cleavage will be used at all times during the session for all clients.

The licensed therapist must immediately end the massage session if a client initiates any verbal or physical contact that is sexual in nature.

If the client is uncomfortable for any reason, the client may ask the licensee to end the massage, and the licensee will end the session. The licensee also has a right to end the session if uncomfortable for any reason.
Do you authorize Camellia Alise, LLC and its representatives to photograph or record you for educational, promotional, advertising, publication, or trade purposes, and release the company from any related claims or liability?*

YesNo
If you do not authorize promotional use, do you understand that photos may still be taken solely for your medical history and progress tracking?*

Yes, I understand
By signing below, you agree to the following. I have completed this
form to the best of my ability and knowledge and agree to inform
my therapist if any of the above information changes at any time.
Client Signature*

Clear
Date*
Therapist Signature

Clear
Client Release
I, * have read and understand the aforementioned conditions which make hot stone massage contraindicated. The massage therapist/practitioner has discussed this information with me and provided an opportunity for any questions. I have disclosed any and all health risk factors
Please check the following that applies to you.*

I understand the information contained on this form and have disclosed any applicable conditions.
My condition(s) of is/are listed above and therefore make(s) hot stone massage contraindicated. Given this knowledge I hereby give my full consent to receive hot stone massage and take full responsibility of any side effects or harm that may come from my receiving hot stone massage.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Massage Intake Form

Personal Information

Medical Information

Client Release