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  • New Client Health Intake Form

    Submission due : 24 hrs prior to your session.

  • Having trouble submitting?
    If you click “Submit” but do not seeing the Thank You page, a required (*) field may be missing. An error message will appear at the top of the form. If some question doesn’t apply to you, enter “N/A” and complete the submission.

  • Welcome to Aira Massage & Wellness KY

    This is 3 -In -One Intake Form for Relaxational Massage, Hot Stone Oil massage gentle touch, and Customized Therapeutic Massage

    Please check all that apply and answer each section in your own words. Some questions may feel more detailed than expected—especially if you booked a relaxational massage—but completing this form fully helps me better understand your body, health history, and wellness goals so I can provide the safest and most effective session possible. Many clients find the process more beneficial than they initially expected.

    Thank you for taking the time to complete the form and trusting the process 😊

  • Format: (000) 000-0000.
  • Birthday*
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  • Format: (000) 000-0000.

  • A friend sent you?

    Let us know their name below
  • Please check applicable to you today.

  • Contraindication (Absolute)


    At Aira Massage & Wellness KY, we take safety very seriously—for both clients and therapist.  Safety is our top priority at all times.

    If you feel unwell within 3 days of your session, please reschedule or cancel your appointment. If symptoms are still lingering (coughing/runny nose/shedding off stage), kindly wait until you are fully recovered before booking. We are taking extra care to prevent spreading infectious illness so that everyone feels safe & cared. 

    If you have any implanted medical devices or artificial parts in your body, please inform your therapist in advance.  

     

     

  • Check anything applicable below. These listed are absolutely 100% No-go for massage.*

  • Contraindications (Local)

    We will do our best to provide appropriate care based on the information in your health intake (such as post-operative conditions). A local contraindication means we may work on surrounding tissues while avoiding the affected area.

  • Please check any applicable below.*
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  • Hot Stone Oil Massage Contraindications

    -Multiple choices - Please check below regardless you purchased hot stone or not. Please consult your physician if you have anything applicable below before booking session. We'll follow your physician's (MD) instruction.
  • Please check any applicable below. :*
  • Do you have any allergies or hypersensitivity for example nuts/particular type of oils, cream, wax, lotion/latex/fragrance/essential oils?*

  • Looking for targeted relief for chronic pain, tightness, or a more personalized full-body-like (not total full body but it is pretty efficient/effective) approach?Customized Therapeutic Massage requires a few additional questions so your session can be tailored to your specific needs.

    If it is not applicable, just put 'NA' to avoid errors.
  • Did you get your medical professional's diagnosis on your pain/discomfort?*
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  • Cause of the pain/discomfort?

  • The Main symptom of your pain/discomfort 

  • What is your main symptom of pain /discomfort specific to your session chosen?*

  • The Main area of your pain/discomfort

  • Check anything applicable related to the main discomfort or pain for the session.*
  • Are you currently receiving ongoing recovery care?*

  • Timing of most painful/uncomfortable regarding your problem area  (Not applicable? Just put 'NA')

  • Movement Restriction

    Any chores you usually do became harder to do? *If you have any Joint Replaced, we are not doing the joint movement or massage right on that area unfortunately since it is out of our scope to treat, please consult your Dr. and Physical Therapist for further assistance for specific recovery care. Replaced part's like hip or knee, life of part is commonly last about 10 years or so if it is cared properly, and highly recommended to keep moving that part based on PT instruction instead of resting all time do nothing which is pretty hard in reality with pain. What we can help is to loosen up the surrounding area of muscles. Regular basis massage can help prevent the joint damage, injuries in the future, well worth the investment!!

  • Is your main pain/discomfort related to an Motor Vehicle Accident in the past or recent one?

    *Please wait at least 72 hours for making massage appointment from the date of the incident* If you got in an accident and experiencing Whiplash effect, please explain below.
  • Check anything applicable for what you were doing right before & upon the motor incident impact.
  • What kind of treatment you tried for treating the motor incident caused pain?
  • Are you still receiving the care you mentioned above?
  • Are you currently taking any medication for your discomfort or pain?

  • COVID Waiver

    -Multiple Choices-
  • COVID 19 Questionnaire In the past 14 days have you experienced any of the following symptoms?*

  • Cancel Policy

  • Cancelling with less than a 24 hr notice is subject to a 100% of the service cost. We DO NOT accept texting or social media messaging for cancellations. Client is responsible to process their own Change/Cancel Appointment from provided Emails 24 hours prior to scheduled session. 


    Same-Day Booking Policy
    Must book  4 hours in advance & Submit the Health Intake asap.
    No refunds for missed or canceled same-day appointments—full charge applies.

    We understand life happens and made easy this process of Change/Cancel appointment up to 24 hours prior to your session date.

    Check your Confirmation E-mail or Reminder Emails, click the button "Change /Cancel Appointmet" 24 hr in advance or Leave a voice message by calling 502.373.1807 if you can't use Email due to Poweroutage.

     

  • Client Arrival & Health Intake Form Policy

  • To ensure you receive the full benefit of your scheduled massage session and to respect the time of all clients:

    Late Arrival: If you arrive late to your appointment, your session will still end at the originally scheduled time. This ensures that other clients are not delayed. Full payment for the session is still required.

    Extremely Late Arrival: If you arrive more than 15 minutes late, it will be considered a missed appointment at the practitioner's discretion, and your session may be canceled without a refund.

    Incomplete Health Intake Form: If you fail to complete the required health intake form prior to your appointment, the time spent filling it out will be deducted from your session time. Please make sure to fill out incomplted section if you have trouble submitting the form. The error will shown on the top of the screen if you have incompleted section. 

     

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