New Client Intake Form and Covid Waiver

Client Intake Form
Name*

First NameLast Name
Phone Number*
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Occupation
Emergency Contact*
Emergency Contact Phone Number*
Format: (000) 000-0000.
The following information will be used to help plan safe and effective massage sessions.

Please answer the following questions to the best of your knowledge.
Have you had a professional massage before?

YesNo
How often do you receive massage therapy?
Frequency
Do you have any difficulty lying on your front, back, or side?

YesNo
Please Explain:
Do you have any allergies to oils, lotions, or ointments?

YesNo
Please Explain:
Do you have sensitive skin?

YesNo
Are you wearing

Contact LensesDenturesA Hearing Aid
Do you sit for long hours at a work station, computer, or driving?

YesNo
Please Explain:
Do you perform any repetitive movement in your work, sports or hobbies?

YesNo
Please Describe:
Do you experience stress in your work, family, or other aspects of your life?

YesNo
How do you think it has affected your health?

Muscle TensionAnxietyInsomniaIrritabilityOther
Is there a particular are of the body where you are experiencing tension, stiffness, pain or other discomfort?

YesNo
Please Identify:
Do you have any particular goals in mind for this massage session?

YesNo
Please explain:
Circle any specific areas you would like the massage therapist to concentrate on during the session
Medical History

In order to plan a massage session that is safe and effective, we need general information about your medical history
Are you currently under medical supervision?

YesNo
Please explain:
Do you see a chiropractor or acupuncturist?

None CurrentlyYes, acupuncturistYes, chiropractorYes, both
How often?
Are you currently taking any medications?

YesNo
Please list medications:
Please list any surgeries & major injuries you have experienced in your life:
Please check any condition listed below that applies to you:

Contagious skin conditionPhlebitisOpen sores or woundsEasy bruisingRecent accident or injuryOsteoporosisJoint disorder/rheumatoid arthritis/osteoarthritis/tendonitisDeep vein thrombosis/Blood clotsRecent fractureEpilepsyRecent SurgeryHeadaches/MigrainesArtificial JointSprains/StrainsCancerDiabetesCurrent feverDecreased sensationSwollen glandsBack/Neck problemsAllergies/SensitivityFibromyalgiaHeart conditionTMJHigh or low blood pressureCarpal tunnel syndromeCirculatory DisorderTennis ElbowVaricose VeinsAtherosclerosisPregnantOther
Please explain any condition that you have marked above:
Is there anything else about your health history that you think would be useful for your massage practitioner to know to plan a safe and effective massage session for you?
You will be fully covered with a drape for the entirety of the massage session. Only the area being worked on will be uncovered. Clients under the age of 17 must be accompanied by a parent or legal guardian during the entire session. Informed written consent must be provided by parent or legal guardian for any client under the age of 17.
I, First Name* Last Name* understand that the massage I receive is provided for the basic purpose of relaxation and therapeutic relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness and that nothing said in the course of the session given should be construed as such. Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist's part should I fail to do so.
Signature*
Date*

MonthDayYear
Date
New Client Agreement and Cancellation Policy
Thank you so much for choosing to work with Tess Falk, MMT, LMT, and Abiola Washington, MMT, LMT. Please read and initial next to each statement.
I, the client of @Peace, understand that @Peace will provide a clean, friendly, comfortable, and health conscious environment to receive therapeutic massage.*
I, the client of @Peace, understand it is my responsibility to arrive 5 minutes early or exactly at the booked appointment time. Any late arrival will result in the loss of corresponding service time. At the booked appointment time, I am to come to the studio door to be let in. The studio door will be locked at all times. I will text @Peace as soon as safely possible to inform them if I will arrive late. *
I, the client of @Peace, understand that @Peace must provide a minimum of 24 hours notice in the unforeseen event that a booked service must be canceled. The exception to this is in the event that the booked massage therapist has a contagious illness or family emergency.*
I, the client of @Peace, understand that @Peace has a strict 24 hour cancellation policy. I agree to provide @Peace with a minimum of 24 hours notice in the event that I must cancel a booked appointment. I understand it is my sole responsibility to communicate any onset of illness or emergency as soon as possible to potentially avoid any cancellation fees. I agree to notify @Peace of any cancellation via text message as soon as possible. I understand that if I cancel a booked appointment less than 24 hours before scheduled, I may be subject to a fee at @Peace's discretion. I understand @Peace has a waiting list and the fee may be waived in the event the cancelled appointment time was filled from the wait-list. I understand that late cancellations will be discussed on a case by case basis and the corresponding fees are discussed on a case by case basis as well. I understand that I may be held liable for the full appointment cost if I choose to not communicate any cancellation. *
I, the client of @Peace, understand that @Peace will send a reminder text through Square Appointments 72 hour's prior to the scheduled appointment time. I understand that clicking the confirm appointment link and verifying my confirmation is necessary. In the event that I do not confirm the appointment through Square Appointments @Peace will assume that I am keeping the scheduled appointment time. I understand that I will be charged the full amount of the booked service in the event that I do not arrive to my appointment.*
I, the client of @Peace, understand that @Peace may not have availability with short notice appointment requests. All efforts will be made by @Peace to accommodate short notices. In the event of an emergency injury or discomfort, @Peace will rearrange the schedule, if at all possible.*
I, the client of @Peace, understand that in the event that @Peace is fully booked during a requested time, I will be placed on a waiting list. In the event of a cancellation, @Peace will text clients on the waiting list with as much notice as possible.*
I, the client of @Peace, understand that payment is due at the time service is rendered.*
I, the client of @Peace, understand that the only accepted forms of payment are check or card.*
I, the client of @Peace, understand that @Peace is closed on Tuesdays and Wednesdays. I understand that if my appointment is on a Thursday, a cancellation will be considered a late cancellation if not communicated by Monday @6pm. All late cancellation agreements apply as stated above.*
I, the client of @Peace, agree to all of the above policies.*
Date*

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

Client Intake Form

The following information will be used to help plan safe and effective massage sessions.

Medical History

New Client Agreement and Cancellation Policy