• The Beauty Therapist Massage Intake Form

    The Beauty Therapist Massage Intake Form

    All information is held confident. At no given point is information disclosed or shared without client’s written consent. 
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  • Health Information

  • Please check any symptoms that apply:

  • Appointment

  • Client information are confidential and written authorization is required to release any information.

    We do not double book appointments

    Please reschedule session if more than 15 minutes late

    24 hour cancellation notice is required 

    You will be draped and at no time be exposed

    You will have a consultation with your therapist to discuss the session

    You may end the session at any time for any reason

    Inappropriate behavior will not be tolerated and may be prosecuted to the full extent of the law


    Client Agreement:

    I know and understand the following:

    • Students of TBTMI completing their studies will provide ONLY a Swedish massage in the Intern Clinic.
    • The massage will be given in a private room, the door in our intern massage clinic will be slightly open.  This is to enable a Massage Therapy Instructor intermittently conducting a walk-through student observation during the massage.
    • The Swedish massage given in the clinic is for stress reduction, relief from muscular tension, and for enhancing the circulation. Students are encouraged not to perform any deep bodywork.
    • Proper client draping procedures protects the modesty of each client and therapist. There will be NO DEVIATION from the established draping protocol.
    • I understand that this massage is NOT to be used in lieu of medical treatment.
    • Intern Therapists are prohibited from prescribing, diagnosing or treating any medical condition. It is recommended that I see a physician for any medical problems I might have.
    • I have submitted correct information regarding my state of health, medical history, injuries, and/or surgeries undergone.
    • I am free of communicable disease.
    • It is necessary for me to arrive 15 minutes before each appointment to have an interview with the intern therapist.
    • I am expected to make all appointments as scheduled. If I must cancel an appointment, I will do so 24 hours in advance.
    • I will be expected to complete an Intern Evaluation Form after each massage for the educational benefit of the intern therapist. An honest opinion of the massage is requested.
    • I understand that the school does not accept any responsibility for any valuable items that I bring with me to the Intern Clinic.
    • Texas Massage Law prohibits massage or manipulation of the breast tissue of a female without prior written consent.
    • I understand that inappropriate comments or conduct will NOT be tolerated.  Any indication of inappropriate behavior will result in immediate termination of the session, and blocking of further sessions.
    • I understand that if either party becomes uncomfortable, they each reserve the right to terminate the session.
    • I understand that if I need help getting on or off the table I must voice that to the therapist or front desk.  I agree that TBTMI is not responsible if I slip or fall.
    • I understand that TBTMI, does not offer massages to any minors without a supervising adult present
    • I understand that TBTMI, does not offer massages to women that are pregnant.
    • I understand the intern will not be able to massage anyone that had surgery in the past 6 weeks.
    • I understand that therapeutic massage therapy does not diagnose and heal illness, disease, any physical or mental disorder.
    • I acknowledge that massage therapy is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service.
    • I understand that this treatment is designed to address the care and prevention of myofascial pain and dysfunction.
    • I understand that at any time I feel pain or discomfort during the session, I will immediately inform my therapeutic massage therapist.
    • I have stated my pertinent medical conditions, and will update the massage therapist of any changes in my health status.

    By my electronic signature below, I agree to the massage policy and client agreement above. 

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  • TBTMI/Deja Vu Spa Massage Therapy Intake form

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