Client Intake and Consent

Prior Surgeries (please describe and provide dates)
Auto Accidents (please describe and provide dates)
Falls/Injuries (please describe and provide dates)
Pregnancies (please describe and provide dates)
Please indicate the areas you would like the therapist to focus on during your session.*
Please indicate any areas you would like the therapist to avoid during your session.*
Please indicate any areas that are particularly ticklish or sensitive.*
Is there anything else your therapist should know before your session?
Include any relevant information about your health, preferences, or concerns that haven’t been covered above.

Terms and Conditions

Review of Session
Please click the submit button below after reviewing the following information. The therapist will review your health and medical information and discuss the type of massage or manual lymphatic drainage services or techniques that may be used during your session. They will describe the body parts that will be treated. Standard draping will be used unless otherwise agreed to by both the client and the therapist. You may stop the session at any point for any reason. Breast massage is not performed without written consent.

Late/Cancellation Policy
Please arrive at least 5 minutes before your scheduled appointment to ensure a full session. New clients should arrive 5–10 minutes early to complete paperwork. If you arrive late, you will receive the remaining session time but will be charged for the full scheduled service. Arrivals more than 15 minutes late will be rescheduled. Cancellations made 24 hours or more before the appointment will not be charged. Cancellations less than 24 hours before the session will be charged 25% of the scheduled service. Cancellations less than 12 hours before the session will be charged 50%. If you do not call to cancel or do not show up, you will be charged 100% of the scheduled service.

Sick Policy
Both therapists and clients are vulnerable to infection from contagious illnesses. If you are feeling unwell, please reschedule your appointment. Clients with any of the following illnesses, or any other contagious illness not listed, will be rescheduled: vomiting, fever, cold, influenza, diarrhea, measles, mumps, rubella, chicken pox, head lice, scabies, impetigo, meningitis, conjunctivitis, hepatitis A, thrush, polio, ringworm (body, feet, or scalp), meningococcal disease, and whooping cough.

Consent / Liability Statement
I understand that the session I receive is provided for the basic purpose of relaxation, relief of muscular tension, and/or improvement of lymphatic flow. If I experience any pain or discomfort during the session, I will immediately inform the practitioner so that the pressure, techniques, or strokes may be adjusted to my level of comfort. I further understand that massage, manual lymphatic drainage, or bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment, and that I should consult a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that practitioners are not qualified to perform spinal or skeletal adjustments, diagnoses, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session should be construed as such. Because these services should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I understand that the practitioner may end the session if they feel uncomfortable for any reason. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.
I have read and understand the above policies and consent statement and agree to them.*

I agree
I understand that all treatments at this facility are therapeutic in nature. I agree to communicate to the therapist any physical discomfort or draping issues during the session.*

I agree
I understand that Béni Massage and Wellness is located in a building that locks automatically in the evenings and on weekends. I will wait for the therapist to open the door for me and will not leave before my appointment time. I recognize that if I leave before my appointment time, I will be charged a no-show fee. Béni Massage and Wellness is located in a two-story red brick building with a green awning in front of the Megaton Brewery.*

I agree

Signature
Complaints
An individual who wishes to file a complaint against a massage therapist, a massage therapy school, a massage therapy instructor, or a massage therapy establishment may write to:

Complaints Management and Investigation Section
P.O. Box 141369
Austin, Texas 78714-1369

You may also call 1-800-942-5540 to request the appropriate form or obtain more information.
Consent to Treatment of Minor
By submitting this form, I hereby authorize the practitioner to administer massage, bodywork, or somatic therapy techniques to my child or dependent as they deem necessary.
Name of Parent/Guardian (if consenting for a minor)
Practitioner Signature

Clear
Client Signature*

Clear
Services are provided by Beni Massage and Wellness LLC, operating under the name “Béni Massage and Wellness.”
Should be Empty:

	Yes	No
Are you currently undergoing cancer treatment?
Are you currently undergoing radiation treatment?
Did your doctor recommend MLD?
Do you have written permission from your treatment team to receive MLD at this time?
Do you give written permission to contact your treatment team to receive MLD at this time?
Are all surgical sites fully healed?

	Yes	No
Did your surgeon recommend post surgical MLD?
Have you been cleared by your doctor to receive MLD?
Have you already received MLD after your surgery?

	Yes	No
Have you experienced any issues with blood clots or clotting?
Were drains used following your procedure?
Were you in a compression garment after your procedure?
Are you currently wearing post-surgical garments?
Are you noticing any thickening or fibrosis in the treated areas?

Client Intake & Consent