Clinical Intake Form. Use ONLY for Clinical, Buccal, TMJ Massage And Stretch Therapy

CLINICAL MASSAGE INTAKE FORM

Let’s Customize Your Session
Client Information
Full Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Email Address
Please use your personal email so you don’t miss appointment updates or spa offers.
Gender
Birthday

MonthDayYear
2 digit month, 2 digit day, 4 digit year
What would you like to feel after today’s session?
How did you hear about Somatic Massage Therapy & Spa?
Preferred Therapist (Optional)
To help us provide the best treatment experience possible, do you have a preference for the gender of your massage therapist? We'll do our best to accommodate your preference based on therapist availability. If we can't, we'll contact you before your appointment or before your session begins.
Are you using a gift card or gift certificate today?
How would you like to provide your gift card details?

Other
Please enter the Gift Card / Gift Certificate Number and Value (if known)
Please upload a photo of your gift card or gift certificate.

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HEALTH HISTORY AND PAIN MANAGEMENT INFORMATION
- Have you had a professional massage before?
- Is this appointment for Intra-Oral Buccal/TMJ Massage?
- Absolute Contraindication Please check all that applies:
- If you answered YES to any of the above, please explain:
- Show us your pain and discomfort areas:
- Are you aware of any tension holding spots in your body?
- If yes, where?
- Please describe any surgeries, hospitalizations, accidents, or injuries.
- What kind of care did you receive for your accidents or injuries?
- Are you currently dealing with ongoing pain or tension?
- What type of pain are you experiencing?(Check all that apply)
  
  Other
- How intense is your discomfort today?
  
  1
  
  2
  
  3
  
  4
  
  5
  
  1 is Low Pain, 5 is High Pain
- Based on your current pain level, we recommend enhancing your massage with our Deep Relief CBD Infused Oil for targeted inflammation and muscle recovery. We also offer our Deep Relief aromatherapy blend (eucalyptus, peppermint, rosemary) if you prefer a sensory-focused approach.
  
  Please note: Our CBD Infused Oil contains trace amounts of THC. If you'd like to add either option to your massage, please notify your therapist or the front desk. (+$45 CBD or +$20 aromatherapy blend)
- Please describe what (if anything) makes your pain better.
- Do you have any allergies to oils, lotions, or ointments?
- If yes, please specify any allergies or sensitivities:
  Including latex, fragrance, AHAs, penicillin, pollen, Biofreeze, menthol, or similar products etc.
- List any medications you are taking, including pain relief medication.
- List any conditions that have or continue to affect you.
  Musculoskeletal, respiratory, circulatory, etc.
- Are there any areas you do not want worked on today?
- Which areas need the most attention today?
- Is there anything your therapist should know to make your session safer, more comfortable, or more effective?
- Please mark any areas of pain, tension, swelling, or discomfort.
- Do you have any relevant medical notes or findings you'd like to upload? (Optional)
- Upload any medical documents that may be helpful to your therapist.
  
  Cancelof
- Maximize your results! Would you like to optimize your clinical massage with a specialized add-on to get lasting relief from pain and stress?
- Session Enhancements
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  Cold Stone Cryotherapy
  Our cold stone application add-on is a refreshing way to reduce inflammation, soothe headaches, and calm muscle spasms. It's the perfect invigorating boost for lasting relief.
  
  $35.00 Quantity
  Item subtotal:$0.00
  
  
  
  30 Min | Pain Relief Red Light Therapy
  Harness the power of light to heal. Our Red Light Therapy reduces inflammation, soothes muscle soreness, and accelerates your body’s natural recovery process.
  
  $40.00 Quantity
  Item subtotal:$0.00
  
  
  
  Headache Relief Essential Oil Blend
  Add extra relief to your session with your choice of CBD-infused oil or Headache Relief Blend. The headache blend combines peppermint, lavender, and other soothing essential oils to melt away stress and discomfort, while CBD supports deep muscle relaxation and overall wellness.
  
  $45.00 Quantity
  Item subtotal:$0.00
  
  
  
  30 Min | Ultrasound Therapy For Pain
  Deep heat therapy for targeted pain relief. Ultrasound waves penetrate deep into tissues, reducing inflammation and accelerating the healing process for lasting comfort.
  
  $45.00 Quantity
  
  
  
  Theragun Muscle Massager
  Target and relieve muscle pain instantly with our Theragun percussive therapy add-on. Break up knots and improve mobility for faster recovery and relief.
  
  $45.00 Quantity
  Item subtotal:$0.00
  
  
  
  Basalt Hot Stones
  Enhance your clinical massage with therapeutic heat. Adding hot stones targets deeper muscle layers, easing tension, improving circulation, and promoting profound relaxation for both body and mind.
  
  $35.00 Quantity
  Item subtotal:$0.00
  
  
  
  40 Min | Table Steam Sauna
  Enhance your clinical massage with our 40-minute Herbal Steam Canopy. Detoxify, support immune function, and inhale the therapeutic blend of ginger, rosemary, eucalyptus, and clove. Leave feeling renewed, energized, and deeply relaxed.
  
  $65.00 Quantity
  Item subtotal:$0.00
  
  
  
  CBD Infused Oil
  Elevate your clinical massage with our CBD-infused oil. Calm inflammation, relieve muscle tension, and enhance relaxation while promoting overall wellness and a deeply soothing experience.
  
  $45.00 Quantity
  Item subtotal:$0.00
  
  
  
  Total
  
  $0.00
- Consent Form
- SCOPE OF PRACTICE
  Massage therapy is a profession in which the practitioner applies manual techniques, and may apply adjunctive therapies, to positively affect the health and well-being of the client. Massage Therapists do not diagnose or prescribe for medical conditions nor are they allowed to provide treatment for a specific condition without a doctor's supervision. The massage therapist is required to refer you for diagnosis and to follow the recommendations of your physician. The massage therapist is happy to adjust pressure, and table temperature, work longer on an area, or move on if you request it.
  
  MEDICAL CONDITIONS
  It is the client's responsibility to keep the massage therapist informed of any medical treatment currently being taken, and to provide written permission from the physician, physical therapist, etc., that the massage may be continued. The client must also inform the massage therapist of any changes in health conditions.
  
  CANCELLATION POLICY
  Our goal is to provide quality care in a timely manner. In order to do so, we have had to implement an appointment/cancellation policy. Appointments are in high demand, and your early cancellation will give another person the opportunity to have access to timely care. This policy enables us to better utilize available appointments for our clients.
  
  If you need to cancel or reschedule your appointment you must call at least 24 hours prior to your appointment, providing less than 24 hours' notice will require you to pay the full-service price as a fee. If you arrive more than 15 minutes late for your appointment without notice it is considered a no-show and you will be charged the full-service price to your card on file.
- By signing below, I confirm that I have read and agree to receive massage therapy. I understand that massage is not a substitute for medical care, I will communicate any discomfort during my session, and I agree to the cancellation and no-show policy.
- Today's Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
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CLINICAL MASSAGE INTAKE FORM

Client Information

HEALTH HISTORY AND PAIN MANAGEMENT INFORMATION

Session Enhancements

Consent Form