Bettye O Massage Form

Bettye O. Day Spa Massage Intake Form
Note: This form is only for first-time massage clients. If you have booked a massage appointment, please complete this form before your visit to ensure the best experience.

This intake form helps our therapists understand your needs, preferences, and any medical considerations to provide a safe and personalized treatment.

If you have any questions, feel free to contact us before your appointment.
Name

First NameLast Name
Birthday

MonthDayYear
Date
Phone Number

Area CodePhone Number
E-mail
Identify Areas for Focus

Use your finger to circle or mark areas on the body map below where you feel pain or discomfort. This will help your massage therapist customize your session to your needs.

Important: Do not mark the genitals, breasts, or midline of the glutes, as these areas will not be massaged.

If you need help or have questions, please ask the therapist before starting your session.

You can use the eraser or clear button if you need to make changes.
Please select any of the following that apples to you:

High or Low Blood PressureDiabetesKidney diseaseCancerSpinal injuriesAmputated limbMissing organ (i.e. left lung, kidney)Recent abdominal surgery (post natal, tummy tuck, hysterectomy, etc.)Rheumatoid ArthritisOsteoporosisLeukemiaUse Blood ThinnersHeadaches/ MigrainesRecent Surgeries (limbs, neck, low back, shoulders, etc.)Skin AbrasionsBruise easilyPlantar FasciitisFibromyalgiaTicklish feet or other areas of bodyCold hands and feetIrritable Bowel Syndrom (IBS)AllergiesArthritisJoint ReplacementHeart diseaseHeart attackNumbnessSprains or strainNeuropathyOther
Are you taking any medications?

YesNo
Are you currently pregnant ?

YesNo
Have you ever had blood clots?

YesNo
Have you ever had any type of dislocations?

YesNo

If you are getting a massage for pain relief or management, rate your pain on a scale of 1 to 10, with 1 being the least pain ever felt by you and 10 being the most amount of pain

	1	2	3	4	5	6	7	8	9	10

1 is Least , 10 is Most

Are you allergic to any oils or creams?

YesNo
If yes list them here:
Please review the following and confirm your acknowledgment by signing your name at the end.

I, the undersigned, voluntarily request and consent to receive massage therapy and related procedures from the Bettye O Day Spa licensed massage therapist.

I acknowledge that I have had the opportunity to discuss the nature, purpose, and expected benefits of my massage session, including the areas of my body that will be addressed.

I understand that while massage therapy is generally safe and beneficial, there are some potential risks, including but not limited to temporary discomfort, muscle soreness, and minor bruising. I recognize that the massage therapist cannot anticipate or explain all possible risks and complications, but I trust their professional judgment to act in my best interest based on the information available at the time of my session.

I acknowledge that my massage therapist is not a medical professional and does not diagnose, prescribe, or provide medical treatment for any condition. I understand that massage therapy is not a substitute for medical care and that I should consult a healthcare provider for any medical concerns.

If at any time I experience discomfort or wish to modify or stop the session, I will communicate this to my therapist, and they will adjust or discontinue treatment accordingly.

I affirm that I have disclosed any relevant health conditions, injuries, allergies, or sensitivities that may affect my treatment. I understand that failure to provide accurate health information may increase the risk of adverse reactions.

By signing below, I confirm that I have read and understand this consent form, have had the opportunity to ask questions, and agree to receive massage therapy under the terms outlined above. This consent applies to today's session and any future sessions unless otherwise revoked in writing.
Please sign this form using your finger to confirm that you agree to the above statements.*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Bettye O. Day Spa Massage Intake Form