Women's Massage Intake Form

Welcome to Soultree Moves Women's Massage

Please complete this form and I'll be in contact with you shortly! Elyse
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Postcode
Phone Number*
Age *
Do you identify as a female?*
Emergency Contact *
Phone Number*
Which type of massage/s are you interested in?

1hr - Relaxation or Deep Tissue - $1301.25hr - Sensual Massage - (oil) - $1451.25hr Relaxation or Deep Tissue - $1451.5hr - Sensual Massage - (oil) - $1701.5hr Relaxation or Deep Tissue - $170Pamper Day - 3 women or more - starting at $600 (please note, in this instance, each woman will need to fill out this form seperately)Other
Pamper Day Option Only - Could the host/organiser please state each participants name here and encourage a seperate form to be filled in please.
Are you currently experiencing any of the following?*

AsthmaMuscular InjuryJoint InjuryPregnancyHigh blood pressureLow blood pressureDizzy/Fainting spellsEpilepsySeizuresDiabetesSleeping IssuesSurgery in the last 5 yearsPanic attacksAnxietyDepressionPTSDSkin conditionsFlu-like symptomsTrauma related issuesSkin ConditionsOther
Are you experiencing any pain in your*

NeckShouldersUpper backLower backLegsHipsArmsHead or faceOther
We predominantly use Almond Oil for the body and essential oils for the face. Do you have any allergies to oils for the body or essential oils that you know of?
Cancellation and No-Show Policies

We understand that unanticipated events happen occasionally in everyone's life. In our desire to be effective and fair to all clients, the following policies are honoured.

- Please give us 24hrs notice of cancellations otherwise it will result in a 50% charge to your account.

- Missing an appointment without proper notification will result in a 50% charge to your account.

- If you arrive late, your session may be shortened in order to accomodate following appointments. Depending on how late you are, your therapist will determine the best treatment plan for the time reamining. You will still be responsible for the 'Full' sessions payment.
Disclaimer (Please Read Carefully)

I hereby request and consent to the service of massage therapy treatment and other massage procedures by the massage therapist.

I am aware of the benefits and risks of massage and that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments and that there may be additional risks based on my physical condition.

I understand this experience entails the use of massage oil, essential oil, music, breathwork, meditation and massage.

I understand that I will have the opportunity to discuss with the therapist the nature of the massage treatment and any other procedures.

I understand that this a massage therapy session and does NOT include sexual services.

I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status.

I understand that I have the right to notify the therapist if the pressure needs to be altered and that I am also able to terminate the treatment at any time.

I understand that I will be draped at all times (unless requested otherwise) and that undraping my breasts and gluteals is part of the procedure - of which I can request an alteration if Im not comfortable.

I understand the risks associated with massage therapy include, but are not
limited to:
• Superficial bruising
• Short-term muscle soreness
• Exacerbation of undiscovered injury
I therefore release the company and the individual massage therapist from all
liability concerning these injuries that may occur during the massage session.

I have been given a chance to ask questions about the massage therapy session and my questions have been answered.

I have read and consent to the above, and by signing below I agree to the above named procedures.
Are there any parts of your body that you are uncomfortable with being massaged?

BackBreastsLegsArmsFeetGluteals (buttocks)HandsHeadTummyFaceOther
Signature*
Date*

MonthDayYear
Date
I agree to all of the above and that i have been open and honest about my health*

Yes
Payment Method

Once you have filled in this form, you will be contacted to make a time for your session.

Pre-payment is required to secure your booking via this link:

https://www.trybooking.com/CXWDW
What days and times are you generally available? You can click more than 1!*

Between the hours of 9 -5pm weekdaysAfter the hours of 5pm weekdaysWeekends onlyIt will vary each time
How would you prefer to be contacted when making the appointment time?*

Phone callTextEmail
Would you like to be a part of our Referral Program? For every person you refer, that books in for this experience, you receive a 20% discount from your next massage. 1 discount per massage applies.
Were you referred by anyone?

First NameLast Name
How did you find out about us?*
Should be Empty: