Client Information
Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
Health Data
Do you have any allergies?
If yes, please specify on the field above.
Current medications
If yes, please specify on the field above.
Are you pregnant? (Female only)
If yes, please specify on the field above.
Have you been recently injured? Some acute injuries may contraindicate massage therapy.
If yes, please specify on the field above.
Do you have any current injuries? Sensitive areas? Areas of caution? Or any areas you do not wish to be massaged at all?
If yes, please specify on the field above.
Current medical conditions
If yes, please specify on the field above.
Areas you would like me to focus on
Benefits/Risks of Massage
Massage provides support in general wellness, decreased inflamation, improved range of motion, stress reduction, relief of muscular tension. Massage is not a replacement for medical care. Your therapist can and will not diagnose. Massage: Superficial Bruising, muscle soreness, exacerbation of undiscovered injury. Please inform doctor before receiving treatment to rule out any total contraindications before treatment. This is to the benefit of the client as I believe in 'do no harm". Contraindications: contagious diseases, being under the influence of drugs/alcohol, pain meds, muscle relaxers, blood clots, bruising easily, hemophilia, injured areas, open wounds, infections, acute skin conditions, sunburns, skin lesions, cancer (talk to doctor), herniation, hematoma, varicose veins, edema and certain medications
Payment Policy
CREDIT CARD OR DEPOSIT of 50% OF TOTAL COST IS REQUIRED TO RESERVE APPOINTMENT. I prefer cash for payment of services but accept paypal, cashapp, venmo and square for payment. Square has service fees added to the total. Payment is due at time of treatment. No exceptions. ALL EVENT / MOBILE SERVICES HAVE AN AUTOMATIC 20% GRATITUITY ADDED TO TOTAL COST.
Appointment Policy
Cancelation policy:Cancelations less than 24hrs prior will be charged 100% of the amount of service. No show policy: no show will be charged 100% of the amount of service. Late policy: Your appointment is strictly within the scheduled time. Late arrival will ultimately shorten the services provided; the original time will be charged.
Arrival Instructions.
Please arrive 5 minutes prior to your appointment for a brief meeting about treatment/paperwork/etc!! Please do not arrive earlier than 5 minutes before your appointment to respect others privacy coming and going from the studio. Please be mindful that I have only 15 minutes between clients following your appointment. During our meeting we will briefly talk about any updates to medical history and treatment plan. Be mindful of this time.
I understand....
I understand that the massage service offered is for the therapeutic purpose of general wellness, stress reduction, and relief of muscular tension.
I understand there is zero tolerance for any sexual misconduct. This includes any and all sexual advances, requests, and other verbal (jokes & conversations) or physical conduct of a sexual nature and will result in immediate termination of the appointment with no refund.
I understand that I cannot be intoxicated in any way to receive massage therapy.
I understand that if I am late to my own appointment that time cannot be made up and I will still be charged the full amount.
My consent is informed and voluntary and I understand that I may withdraw my consent at any time except for actions already taken.
I have provided my therapist with an accurate and complete medical history. I do not have any injuries or conditions that prevent me from receiving therapy.
If I experience any pain or discomfort, I will immediately inform my therapist so that the pressure or techniques can be adjusted to my comfort level. I will not hold my massage therapist responsible for any pain or discomfort I experience during or after the session.
I have been given the opportunity to ask questions about massage therapy and my questions have been answered to my satisfaction.
By signing this I release Ericka Lafever and Village Bodywork from all liability & understand / agree to all policies.
Signature of the Client or Parent / Guardian if client recieving care is under 18yrs of age
Date Signed
-
Month
-
Day
Year
Date
Submit
Should be Empty: