White Lotus Bodyworks Massage Therapy Intake & Consent Form

Massage Intake & Consent Form

Please fill out this form to help us provide the best care. This form includes client info, consent, marketing preferences, liability waivers, etc. if applicable under Georgia law.
Full Name*

PrefixFirst NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
What's your occupation? What do you do for work? (If not working, what is main form of physical activity?)*
What's your main forms of exercises or sports? History of activity growing up?
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.
Emergency Contact Relationship
Please describe any medical conditions, any former damage to muscles, bones, ligaments, allergies, sensitivities to essential oils or other things to be aware of:*
Are you a vegetarian or vegan (for product use & awareness, products may contain tallow, beeswax, and other animal byproducts)?

Yes, VegetarianYes, VeganNo
What days and times would you prefer your session?*
What are your areas of concern? What would you like focus on?*
Terms & Conditions of Intake & Informed Consent

The purpose is to provide therapeutic massages to help reduce stress and promote wellness in a safe environment. By participating in this massage, I acknowledge and accept all inherent risks and waive liability for any injury or adverse outcome, releasing any organizers, venue, and practitioner Peter Chai from any claims. I confirm I am in good health, consent to treatment areas, and agree that any photos, videos, testimonials, or recordings taken during the treament event may be used for marketing or educational purposes without compensation, if that option is chosen below. I understand massage is not a substitute for medical care, agree to respectful conduct, and accept these terms under applicable local laws. I understand all recommendations are professional opinions and not diagnoses. I consent to receive marketing communications related to future events and promotions. I understand I can opt out at any time.
Marketing/Instructional Content*

I consent to any social media post, stories, pictures, videos, instructionals, etc. and it's ok to show my face, body, name, etc.I consent to any social media post, stories, pictures, videos, instructionals, etc. that show my face and body but I would like to stay anonymousI consent to any social media post, stories, pictures, videos, instructionals, etc. that show my body only but I would like to stay anonymousI don't consent to any marketing/instructional content
Informed Consent*

I consent to all areas and modalities listed below:ScalpFaceIntraoral buccal area (TMJ jaw work with gloves)Chest & latissimus dorsi muscle regionAbdominal & intercoastal muscle regionHip, abductors, & psoas muscle regionGluteal musclesAdductors (inner thigh region)FeetAshiatsu & Sarga Silk bodywork (barefoot technique work)Aromatherapy (use of essential oils such as lavender, peppermint, eucalyptus, sweet orange, etc.) Please indicate if allergic to any oils or anything elseThai Massage stretching & sports stretching (of the neck, arms, shoulders, torso, legs, hips, etc.)Cupping TherapyUse of percussion & focal vibration tools (TheraGun, Hyperice, Tend, etc.)Hot stones, hot towels/compresses, & other heat therapiesCold tools, towels/compresses, ice, & other cold therapiesGua Sha & other scraping toolsVagus nerve stimulation & Neuromuscular Electrical Stimulation (NMES)Use of CBD products
Signature*

Clear
I hereby confirm that the above intake is filled out correctly and to the best of my knowledge under a sound mind.
Should be Empty:

Massage Intake & Consent Form