The Heeling Hut Mega Form

The Heeling Hut Mega Form

This form includes client information, terms of service, health history, and informed consent required to be completed before your first session. It will take approximately 15-20 minutes.
Client Information
Name*

First NameLast Name
Age*
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Details
In case of emergency, we will contact the person below:
Emergency Contact Name*

First NameLast Name
Phone Number*
Relationship*
Terms of Service
24-hour advance notice is required when canceling an appointment. Please call ‪(214) 267-9541‬ and leave a voicemail/text or email me to cancel your massage at least 24-hours in advance*

I agree
If you are unable to give a 24-hour notice, the full rate of the service you reserved off the appointment book is your responsibility. Prepayment may be required to schedule appointments.*

I agree
Habitual rescheduling could result in declining appointment requests.*

I agree
Prepaid massage sessions are voided and marked as used at the full value in the event of a no-show or last-minute cancellation.*

I agree
Appointment times have been arranged specially for you. If you arrive late, your session ends at the initially scheduled time to respect the time of our other clients whose appointments follow yours and to complete regulatory cleaning procedures.*

I agree
Sessions are treated as "no-show" after 45 minutes late on a 90-minute session. Regardless of the length of the treatment given, you will be responsible for the entire fee of the original appointment.*

I agree
All sales are final. Old gift certificates, retail items, massage packages, and classes are included in this policy. Some items may be transferable and gifted to a friend or family member with an original expiration date. Contact me for more details. Please note: I no longer issue gift certificates.*

I agree
Payments are due when services are rendered or in advance with packages and exclusive sales. Special offers can not be combined.*

I agree
All sessions sold in a package or prepaid in the office or online are to be completed within one year of the purchase date. Exclusive promotions and discounted sessions are honored for one year. The Heeling Hut does NOT sell gift cards or gift certificates for services or retail.*

I agree
Forms of payment accepted: Exact amount in cash, credit cards, HSA, FSA, Contactless payments via Venmo or Zelle*

I agree
Hillary Arrieta and The Heeling Hut, LLC abide by the code of ethics of the industry standards described by the American Massage Therapy Association. I am a licensed massage therapist (MT040051), fully certified in barefoot massage techniques. I require a full-sheet drape with no exceptions.*

I agree
We have the right to refuse service to anyone for any reason. Reasons one might be refused include Inappropriate behavior or requests. Requests for services outside my scope of practice. An unwillingness to follow any of the above policies. Communicable illness. Examples: virus, active cold/flu, bacterial infections, etc.*

I agree
Health Data

The following information will be used to help plan a safe and effective massage session. Please answer the questions to the best of your knowledge. These questions are required by the Texas Department of License and Registration.
What massage styles are anticipated for your massage?*
We offer The Barefoot Massage Escape, The Barefoot Massage Adventure, The Heeling Journey, The Shirodhara Ritual, The Seasonal Wellness Ritual, Scalp Massage, Herbal Steam therapy, Cupping Therapy, Infrared Sauna, Red light Therapy. Please check the services page on our website for more information.
Are you under the age of 18? *
You must be at least 18 years of age to receive services at The Heeling Hut Barefoot Massage.
Are you pregnant?*
If yes, please reschedule for a time after your pregnancy and a release from your doctor for compressive, deep tissue massage.
Are you taking muscle relaxants?*
Please avoid taking them 12 hours before your massage.
Fungal, bacterial, or viral infections? *
If yes, when/ where? Please reschedule if in the first three days of taking antibiotics.
Have you ever had a professional massage session before?*
How often do you receive massage sessions? *
Do you have any difficulty lying on your front or back? *
What is your goal for today’s massage session?*

Increased vitality/Well Being.Stress reductionPain reductionOther
How do you respond to stress? *
Is there any particular area(s) of your body where you are experiencing tension, decreased range of motion, stiffness, pain, or other discomforts?*
Location of focus points/ problem areas.*
Do you have any allergies. Please include anything that might be in an oil/lotion.*
If yes, please specify on the field above.
Are you currently taking any medications?*
If yes, Please list any muscle relaxers, blood thinners, topical hormone creams, steroids, injections.
Do you have asthma?*
Do you have migraines?*
If yes, how often? Type?
Skin Conditions? (Warts, Rashes, Infections)*
If yes, where?
Surgery in the last two years?*
List all that apply.
Injuries or health problems needing hospitalization or other medical attention in the past two years?*
List all that apply.
Do you have Cardiac, Blood Clots, Unmedicated High Blood Pressure, Circulatory Problems?*
List all that apply.
Nerve Impingement, Numbness, or stabbing pains? *
If yes, where.
Do you have any Spinal Problems? *
If yes, please explain.
Do you experience neuropathy?*
If yes, Where?
Have you had any broken or fractured bones, Diagnosed Osteoporoses, Osteopenia, Bone density issues, or Diagnosed Arthritis?*
List all that apply.
Do you have varicose veins? (not spider veins)*
If yes, Where?
Are you Diabetic? *
Do you take oral or injected medications?
Hernia or history of hernia? *
If yes, where?
Is there anything else about your health history that would be useful for your therapist to know in order to plan a safe and effective session for you? *
List medications and any medical devices, Examples: pacemaker, Implanted material, artificial valve, medical port, injection sites, topical medicine sites here
Consent and Waiver
I, undersigned, agree with the following statements:*

The type of massage therapy services offered at The Heeling Hut are Barefoot Massage is deep tissue massage. The client agrees to verbally use the pressure scale explained before your massage to communicate with the licensee throughout the session to ensure the pressure is safe and productive.The licensee shall drape the breasts of all female clients and not engage in breast massage of female clients. Breast massage will NOT be performed.Draping of the genital area and gluteal cleavage will be used at all times during the session for all clients.If uncomfortable for any reason, the client may ask the licensee to cease the massage and the licensee will end the massage session. The licensee must immediately end the massage session if a client initiates any verbal or physical contact that is sexual in nature.I acknowledge that all information I provided in this form is true and accurate.
I understand that the massage I receive is provided for the basic purpose of relaxation and relief of tension and stress. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that adjustments can be made 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 physical or mental ailment that I am aware of and that nothing said in the course of the session given should be construed as medical treatment. I affirm that I have stated all my known medical conditions and answered all questions honestly. If the client or therapist is uncomfortable, the client/therapist may end the massage session. 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. You can file complaints on this practitioner to the department by phone at (512) 463-6599, fax (512)539-5698, or mail to TDLR, Enforcement Division, P.O. Box 12157, Austin, Texas 78711.
Signature of the Client*

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Date Signed*

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The Heeling Hut Mega Form

Client Information

Emergency Contact Details

Terms of Service

Health Data

Consent and Waiver