Jade Solace Massage Therapy - Full Massage Intake Form

Hot Stone Release Form

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Hot Stone Massage Contraindications Hot stone massage is not suitable for everyone. There are risks associated with performing hot stone massage on individuals with the following conditions.

You must inform your massage therapist/practitioner if you have any of the following conditions which may make hot stone massage contraindicated or may require your therapist/practitioner to alter the massage.
- Pregnancy
- Blood clot(s)
- Diabetes
- Neuropathy
- Inflammatory skin conditions
- Autoimmune condition (MS, Lupus, RA, etc)
- Open wounds or sores
- Peripheral vascular disease
- Hypotension or Hypertension
- Heat sensitivity
- Cancer (with or without treatment)
- Compromised immune system
- Varicose veins
- Edema or Lymphedema
- Under the influence of drugs or alcohol
- Cardiovascular disease
I First Name* Last Name* have read and understand the aforementioned conditions which make hot stone massage contraindicated. The massage therapist/practitioner has discussed this information with me and provided opportunity for any questions. I have disclosed any and all health risk factors.
Please check the following that applies to you*

I understand the information contained on this form and confirm that I do not have any of the above.My condition(s) make(s) hot stone massage contraindicated. Given this knowledge I hereby give my full consent to receive hot stone massage and take full responsibility of any side effects or harm that may come from my receiving hot stone massage.
I understand that I will be receiving hot stone massage as an adjunct form of healthcare only and that this therapy is not meant to replace appropriate medical care. I release the massage therapist/practitioner of any and all liability for any harm that may unintentionally occur during my treatment(s).
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Prenatal Massage Contraindications

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Massage therapy during pregnancy has been shown to be beneficial for a number of common complaints such as fatigue, musculoskeletal pain, sciatica, edema, and many others. However, there are risks associated with specific conditions that may occur during pregnancy.

You must inform your massage therapist/practitioner if you have or have had in the past any of the following conditions or symptoms which may make massage therapy during pregnancy contraindicated or may require your therapist/practitioner to alter the massage.
- History of miscarriage
- Preeclampsia
- Gestational Diabetes
- History of any high-risk pregnancy
- Cardiac, pulmonary, liver, or renal disorders
- Drug exposure
- Mother's age under 20 or over 35
- Multiples
- Pitting edema
- Hypertension
- Genetic abnormalities
- Epilepsy or other convulsive disorders
- Placental or cervical dysfunction
- Fetal growth retardation
- Abdominal pain
- Bloody discharge
- Leaking of amniotic fluid
- Sudden weight gain
- Fever
- Diarrhea
- Sudden edema/swelling
- Decrease in fetal movement over 24-hour period
- Severe headaches
- Severe nausea or vomiting
I First Name* Last Name*have read the aforementioned conditions and symptoms which make massage therapy during pregnancy contraindicated. The massage therapist/practitioner has discussed this information with me and provided opportunity for any questions have disclosed all high risk factors of my pregnancy.

I have discussed with my prenatal healthcare provider/physician any health concerns that I had about receiving massage therapy. I agree that my healthcare provider/physician has given me clearance to receive massage therapy.

I understand the information contained on this form and confirm that (1) I am receiving medical care including regular check-ups with a licensed healthcare provider. (2) I have not experienced any of the listed symptoms, conditions, or complications. (3) I am not currently experiencing any of the listed symptoms, conditions, or complications. (4) I am experiencing a low-risk pregnancy.

I understand that I will be receiving massage therapy as an adjunct form of healthcare only and that this therapy is not meant to replace appropriate medical care. I release the massage therapist/practitioner of all liability for any harm that may unintentionally occur during my treatment(s).
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Minor Release Form

All persons under the age of 18 are required to have a parent or guardian fill out this form.
By signing below, you agree that you are the parent or legal guardian of the minor receiving treatment(s) at our facility. You understand that you are required to remain at the facility for the entirety of the minor’s treatment(s). You will also be required, if needed, to assist the minor in preparing for his/her treatment(s). We may also request that you remain in the treatment room to supervise all interactions between the therapist and the minor.

You also agree that you have completed the Intake Form and have informed the therapist of all medical diagnoses, symptoms, medications, and complaints associated with the minor receiving treatment(s).
I First Name* Last Name*, certify that I am the parent or legal guardian of First Name Last Name, who is Numberyears of age as of today, Date . I have completed the Intake Form for the above-mentioned minor and informed the therapist of all relevant medical history and concerns. I understand the scope of massage therapy and that it is not meant to diagnose, treat, or cure any conditions and is not a replacement for standard medical care. I give permission for my minor child to receive treatment(s) at this facility and agree to all the above terms.
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General Liability Release Form

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By signing below, you agree to the following:
1. I give my permission to receive massage therapy.
2. I understand that therapeutic massage is not a substitute for traditional medical
3. I understand that the massage therapist does not diagnose illnesses or injuries, or prescribe medications.
4. I have clearance from my physician to receive massage therapy.
5. I understand the risks associated with massage therapy include, but are not limited to:
  1. Superficial bruising
  2. Short-term muscle soreness
  3. Exacerbation of undiscovered injury
  4. I therefore release the company and the individual massage therapist from all liability concerning these injuries that may occur during the massage session.
6. I understand the importance of informing my massage therapist of all medical conditions and medications I am taking, and to let the massage therapist know about any changes to these.
7. I understand that there may be additional risks based on my physical condition.
8. I understand that it is my responsibility to inform my massage therapist of any discomfort I may feel during the massage session so he/she may adjust accordingly.
9. I understand that I or the massage therapist may terminate the session at any time.
10. I have been given a chance to ask questions about the massage therapy session and my questions have been answered.
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Massage Intake Form

In Case of Emergency

Medical Information

Massage Information

Hot Stone Release Form

Prenatal Massage Contraindications

Minor Release Form

General Liability Release Form