Form

Client Intake Form

Please take minute and fill out
Name

First NameLast Name
Today's Date

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
Phone Number
Occupation
Emergency Contact Name
How did you hear about us
Name of person who may have referred you
General Health
Rate your level of stress (1 being lowest, 5 being the highest)

12345
What physical activities do you enjoy?
Do you wear contact lenses?
Are you allergic to Aspirin?
Skin Sensitivities/General Allergies?
Please be Specific
Do you smoke?
Have you seen your doctor for any situation in the last six weeks?
Please list any accidents or surgeries in the last 12 months
Do you have Metal Implants?
Do you have a pace maker?
Do you have an body piercings?
Please list any medications/supplements you are currently taking:
Type N/A if not applicable
Are you currently taking:

AntibioticsBirth ControlBlood ThinnersHormone ReplacementN/A
Health History

ArthritisIrregular DigestionHerpes Simplex VirusMRSAAllergy to Iodine or ShellfishCirculatory ProblemsHypertensionEye Infection of DisorderChronic PainSleep ProblemsVaricose VeinsHeart DiseaseEpilepsySerious Sunburn or ExposureDiabetesClaustrophobiaEczemaPsoriasisSciaticaHyper/Hypotrophic ScarsSun AllergyNONEOther
Have you been diagnosed with Cancer?
Are you Pregnant/nursing or trying to become Pregnant?
If pregnant how many weeks?
type N/A if not applicable
Any other medical conditions or concerns we need to know about?
Massage Therapy
Have you had a professional massage before?
If Yes, when
How often
Often Enough?
Pressure?
Is there any part of your body you would like to focus on today?
Is there any particular issue that your having that you might want to share? (aches, pains, worries)
(Please type no if not)
Goal for your Massage Session

RelaxationPain ReliefStress ReductionHeadacheEscapeHealth and WellnessOther
Are there any areas of your body you do not want massaged?
Are you under the care of a dermatologist?
Skin Type

Oily/CongestedDry/DehydratedSensitive/RednessAcneSunburnedN/A
By signing below, I acknowledge and accept the following terms and conditions: It is my choice to massage treatments, and services. If at any time, for any reason, I want the service to end, I will ask, and the service provider will cease the service immediately. Because massage treatments should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, or answered all questions asked of me honestly. I will update any changes to my health status. I understand that Massage Therapists do not diagnose illness, disease, or physical or mental disorders, nor do they prescribe medical treatments, pharmaceuticals, or perform spinal manipulations or skeletal adjustments and that nothing said in the course of the session given should be construed as such. I acknowledge that these treatments are not a substitute for medical examination or diagnosis, and that it is recommended I see a primary health care provider for that service. If I experience any pain or discomfort during the session, I will immediately inform the Massage Therapist so that the service may be adjusted to my level of comfort or discontinued. I further understand that I am paying for a treatment and not a result and that there will be no returns, refunds or exchanges. If recommended to be used during my service, I consent to the use of Hemp based CBD during my CBD massage. I understand that Hemp CBD has less than 0.3% THC and will not cause any psychoactive symptoms to occur. I acknowledge, however, that in some circumstances the use of CBD products may cause a positive reading on a drug test and CBD product should not be used if I am drug tested for employment or other purposes. I have discussed the use of topical Hemp based CBD with my health care provider and they have cleared me for use during my massage. I acknowledge and understand that the therapist must be fully aware of my existing medical conditions. PLEASE INTIAL BELOW
If I am unable to make a scheduled appointment, I agree to cancel the appointment, I agree to cancel the appointment 24 hours in advance by phone or TEXT or email at pimmy@thaifusionmassage.com. in this case I will TEXT or call or email ASAP to reschedule my appointment. If I miss a scheduled appointment without giving 24-hour notice, I agree to pay a missed appointment fee that applies. PLEASE INTIAL BELOW
I understand that any illicit or sexually suggestive behavior, remarks or advances made by me will result in the immediate termination of the session and I will be liable for payment of the scheduled service. Further, I understand that Thai Fusion Massage Therapy and the Massage Therapist providing the service reserves the right to refuse to administer services at any time at their sole discretion. I have read and fully understand this form in its entirety.
I understand I should undress to my level of comfort. My therapist can perform an effective massage regardless of my level of undress, including continuing to wear undergarments. My service provider will leave the room for me to undress.

Yes
Name
Date
The information I have provided is assurate and true. I hereby release the practitioner, Thai Fusion Massage Therapy and it's owners, and their insurers or agents from all liability of any nature whatsoever, whether past, present, or future, for injury or damage which may occur to myself or my family as a result of my receiving massage or any other related services.
Please type your full name and today's date as an electronic signature
*required
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Client Intake Form

General Health

Massage Therapy