Client Intake Form

Name*

First NameMiddle InitialLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Birth Date

MonthDayYear

E-mail

example@example.com

Phone Number

Emergency Contact

First NameLast Name

Phone Number

Occupation

What activities/hobbies do you currently partake in?

Are you currently seeing any other healthcare professional?

Medications/ Other medical conditions:

Accidents, injuries and/or surgeries within the last year: (please include the date of occurrence)

Allergies/ Skin sensitivities:

Are you pregnant?*

If yes, how many weeks are you currently?

Due Date

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Postpartum 6 weeks or less

Areas that need extra attention: (breast, abdominals/stomach, and genital areas will ALWAYS be avoided)

Any areas to avoid?

4 the Luv of Massage Day Spa Policies and Client Agreement:

Provider name: LaTrissa S. Womack, LMT

Client services and chart information are confidential.

Written authorization is required from you to release any information.

I am aware that I can always undress to my level of comfort. During my session my massage therapist will ensure proper draping at all times. I will remain covered by sheets, blankets, and/or towels unless my massage therapist is working on that area.
At any time during my session the massage therapist reserves the rights to end the session due to any inappropriate activities or behaviors and I may be prosecuted to the full extent of the law.
I understand that I may also end the session at any time if I feel uncomfortable for any reason.
I understand that my session time includes a verbal intake to discuss the focus of my service for today, time to undress and redress.
For optimal relaxation I should turn off or silence my cell phone.
Any appointment that I am more than 15 minutes late to without a call to adjust my session with my massage therapist will be considered a CANCELLATION and will occur a SAME DAY/ NO SHOW fee.
If I can not make it to my scheduled appointment I know I should contact the spa to reschedule it 24 hours prior to the start time to avoid any LATE or NO SHOW fees.

I understand that therapeutic massage therapists do not diagnose illness, disease, any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or perform joint mobilization.

I acknowledge that massage therapy is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service.

It is my choice to receive therapeutic massage as a form of therapy.

I understand that treatment given is designed to address the care and prevention of myofascial pain and dysfunction.

I also undersand that at any time I feel pain or discomfort during the session, I will immediately inform my therapeutic massage therapist so they adjust.

I have stated my pertinent medical conditions, and will update the massage therapist of any changes in my health status.

I understand that my failure to do so may post a threat to my health and/physical well being and I hold harmless Therapy Center and my therapeutic massage therapist from any liability whatsoever arising from failure on my part.

By my electronic signature below, I agree to the massage policy and client agreement above.

Signature

Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.

Date *

Date

Client Intake Form

Health History