New Client Intake Form

New Client Intake Form
Soft Spots Massage Therapy

316-445-3572

soft-spots.massagetherapy.com
Name*

First NameLast Name
Gender*
Phone Number*

Area CodePhone Number
Email*
Your Birthday*

MonthDayYear
May we add you to our email list?
Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code
How do you prefer for us to contact you? *
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
How did you hear about me?*

FacebookInstagramGoogle SearchReferral (type name below)Other
How often do you like to get a massage/bodywork?*
When was your last massage or bodywork?*
What is more important to you?*
A deep, therapeutic massage can leave you feeling sore for a day or two. How do you feel about being sore after your massage?*
What would you prefer during your massage session? *
What are your top priorities to be addressed at your appointment?*

Low Back PainSciatic PainNeck PainHip PainTight Glutes (Butt Muscles)Shoulder IssuesTension HeadachesOther
What are your current issues & how are they affecting you?*
What type of pain are you currently experiencing?*

Stabbing PainElectrical Pain (Sharp Electric Shock)Burning PainAchy PainWidespread Pain & TendernessMuscle SpasmsTension PainSharp Pain, Localized, Small AreaNoneOther
How did your issue/pain begin?*

SlowlySuddenlyIt has gotten worse over time.It has improved over time.I'm not sure how it happened or how it progressed.N/A I do not have an issue or pain.Other
In your entire lifetime, have you ever had any of the following surgeries?*

Any Orthopedic SurgeryCarpal Tunnel SurgeryRotator Cuff SurgeryNeck / Back FusionKnee SurgeryHip ReplacementAnkle SurgeryGallbladder SurgeryHysterectomyAppendectomy (Appendix Removal)Breast SurgeryLymph Node RemovalOther
Please list all surgeries:
HEAD INJURY: Please list any significant head injuries, like concussions, being knocked unconscious, or traumatic brain injury.*
BODY INJURY: Please list any significant injuries to your joints, muscles, or bones. *
Do you have any special needs I should prepare for?
Do you have an implanted electronic device in your body (like a Pacemaker, ICD, or medicine pump)?*
Are you currently pregnant?*
Which prescription medications are you currently taking?*

I am NOT taking any prescription medications.Other
Medical History: If you have experienced any of the symptoms that is marked with an asterisk (*), please contact us to discuss your medical history before booking an appointment; this is to ensure your safety and well-being.

Medical History*

	Current	Past	Never
Pregnancy*
Blood Clots*
Pacemaker*
Congestive Heart Failure*
Unexplained Calf Pain*
Varicose Veins*
Stroke or Heart Attack*
Cancer*
Car Accident*
High Blood Pressure
Low Blood Pressure
Epilepsy / Seizures
Chronic Headaches / Migraines
Chronic Dizziness / Ringing Ears
Digestive Disease (IBS, Crohns, etc)
Chronic Constipation
Chronic Diarrhea
Kidney Disease / Chronic UTI's
Arthritis (rheumatoid, osteoarthritis)
Scoliosis / Kyphosis / Lordosis
Osteoporosis
Degenerative Spine / Disk
Broken Bone
Allergies that Require an Epi-Pen
Autoimmune Condition (Celiac, Hashimotos, Lupus, Graves, etc)
Diabetes / Insulin Resistance
Endocrine / Thyroid Condition
Chronic Depression
Chronic Anxiety
Chronic Swelling
Sensitive to Touch / Pressure
Easy Bruising
Shortness of Breath / Asthma
Chronic Muscle / Joint Stiffness
Chronic Muscle / Joint Pain
Chronic Pain
Chronic Numbness / Tingling
Neurological Condition (ALS, Parkinsons, etc)
Chronic Skin Rash
Highly Sensitive to Certain Smells or Fragrances
Fibromyalgia
Multiple Sclerosis
Memory Loss / Confusion

Etiquette & Policies

Insurance: We provide a therapeutic massage, which is non-medical. We do not work with insurance companies. Any communication with insurance companies is solely the clients responsibility. We are strictly a private-pay facility.

Age Requirement: We do not accept minors (anyone under the age of 18.) All clients must be 18 years of age or older to receive massage therapy treatment.

Cancellation Policy: There is no penalty if you have an emergency or an illness and need to cancel the day of your appointment, but let us know as soon as possible. We will waive the cancellation fee, but you will be unable to reschedule your massage for 2 weeks after any illness. If you need to reschedule or cancel an appointment, we require a minimum of 24-hours notice for massages 1 hour or less and 48-hour notice for massages over 1 hour. If you need to cancel your appointment, please call or text at 316-445-3572, as soon as possible. If we don't answer, leave your information on our voice mail. Appointments made within 24 hours may automatically be subject to cancellation fees.

Payment: Full payment is due at time of service. We prefer cash, but will also accept payment by card.

Conversation: It is your choice to talk to your therapist or remain quiet throughout your session. Your therapist will follow your lead and mirror your decision. There are times that your therapist may need to speak to you to have you reposition, request feedback on pressure, or explain a finding.

Professionalism: All therapies are professional, therapeutic massages, there will be no sexual contact or conduct at any time between any client and a therapist. Should a client behave in a manner that violates this professional boundary, the session will be ended and the client will still be required to pay for the session in full; but will no longer be a client of Soft Spots Massage Therapy LLC.

Thank you for your reviewing our policies, we strive to offer you the best therapeutic experience and look forward to helping you reach your wellness goals.
Special Consent for Massage of Inner Thighs, Gluteal Muscles (Buttocks), & Pelvic Floor

What are these areas?
- Inner thighs: adductor muscles
- Buttocks: gluteal muscles, piriformis, upper and lateral sacrum
- Pelvic floor: ischial tuberosity, sacrotuberous ligament, coccyx, lower sacrum
Why work these areas?

Many times, pain or discomfort in the lower back is due to issues with the muscles in the buttocks, inner thigh, and pelvic floor regions.

Client Education = Empowerment

In order to achieve treatment goals, your therapist may deem it appropriate to work on muscle or connective tissue in the inner thighs, buttocks, and pelvic floor regions.

The anal area and the genitals will always be draped (covered) and will not be touched.

Even if you consent to massage in this area today, you can always choose not to receive it at any point of your treatment. You, the client, have the right to change consent at any time during a treatment.

Please let your therapist know immediately if at any time treatment feels uncomfortable in any way.
Consent for Massage of Inner Thighs, Gluteals, & Pelvic Floor Region*
Informed Consent
By typing my first name, last name, and providing my e-signature below, I am indicating the following:

1. I have read the New Client Intake Form for Soft Spots Massage Therapy LLC in its entirety.

2. I fully understand all questions and information provided in the New Client Intake Form for Soft Spots Massage Therapy LLC.

3. I have completed the New Client Intake Form for Soft Spots Massage Therapy LLC accurately and to the best of my knowledge.

4. I have read and I understand the Etiquette & Policies by Soft Spots Massage Therapy and I agree to the terms and conditions outlined in the Etiquette & Policies
Type Full Name:*

First NameLast Name
Signature*
Today's Date*

MonthDayYear
var onlyCountReq="Yes", fixedProgressBar="Yes", deleteLabelProgressBar="", fieldsProgressBar="Fields Completed", submitProgressBar="Please Submit the Form", requiredProgressBar="Required Fields Complete", theme="Island Blue";
var analyticsFormId = '{analyticsFormId}'; var analyticsAutoLink = ''; (function (i, s, o, g, r, a, m) { i['GoogleAnalyticsObject'] = r; i[r] = i[r] || function () { (i[r].q = i[r].q || []).push(arguments) }, i[r].l = 1 * new Date(); a = s.createElement(o), m = s.getElementsByTagName(o)[0]; a.async = 1; a.src = g; m.parentNode.insertBefore(a, m) })(window, document, 'script', '//www.google-analytics.com/analytics.js', 'ga'); ga('create', 'UA-93101788-1', 'auto', {'allowLinker': true}); ga('send', 'pageview'); if(window.analyticsAutoLink && analyticsAutoLink != ''){ analyticsAutoLink = analyticsAutoLink.replace(/ /g, '').split(/[,\n]/g); ga('require', 'linker'); ga('linker:autoLink', analyticsAutoLink); }
Should be Empty:

New Client Intake Form

By typing my first name, last name, and providing my e-signature below, I am indicating the following:

1. I have read the New Client Intake Form for Soft Spots Massage Therapy LLC in its entirety.

3. I have completed the New Client Intake Form for Soft Spots Massage Therapy LLC accurately and to the best of my knowledge.

4. I have read and I understand the Etiquette & Policies by Soft Spots Massage Therapy and I agree to the terms and conditions outlined in the Etiquette & Policies