Client Intake

Revive & Restore

Therapeutic Massage
Client Intake Form
Name*

Legal First NameLegal Last Name
Preferred Name/Nickname?
Name by which you prefer to be addressed
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date of Birth
Occupation*
Occupation
Emergency Contact
Emergency Contact
Phone Number
Please enter a valid phone number.
The following information will be used to help plan safe and effective massage sessions. Please answer the questions to the best of your knowledge.
Have you had a professional massage before?*

YesNo
If yes, how often do you receive massage therapy?
What have you enjoyed the most about when you have received massage?
Is there anything you have not enjoyed when you have received a massage?
Do you have any difficulty lying on your front, back, or side? Select all that apply.*

Yes - FrontYes - BackYes - SideNo
If yes, please explain
Do you have any allergies to oils, lotions, ointments, or ingredients in these?*

YesNo
If yes, please explain
Do you have sensitive skin?*

YesNo
If yes, please explain
Do you wear (Select all that apply):*

Contact LensesDenturesHearing AidNone of the above
Do you sit for long hours at a workstation, computer, or driving?*

YesNo
If yes, please explain
Do you perform any repetitive movement in your work, sports, or hobby?*

YesNo
If yes, please explain
Do you experience stress in your work, family, or other aspect of your life?*

YesNo
If yes, how do you think it has affected your health? Select all that apply.

Muscle TensionAnxietyInsomniaIrritabilityOther
If you selected "other", please describe
Is there a particular area of the body where you are experiencing tension, stiffness, pain or other discomfort?*

YesNo
If yes, please identify
Do you have any specific goals in mind for your massage and wellness?*

YesNo
If yes, please describe
Medical History

In order to plan a massage session that is safe and effective, I need some general information about your medical history.
Are you currently under medical supervision?*

YesNo
If yes, please explain
Do you see a chiropractor?*

YesNo
If yes, how often
Are you currently taking any medications?*

YesNo
If yes, please list
Please check any condition listed below that applies to you:*

contagious skin condition (including plantar/palmar warts)open sores or woundseasy bruisingrecent accident or injuryrecent fracturerecent surgeryartificial jointsprains/strainsswollen glandsallergies/sensitivityheart conditionhigh or low blood pressurecirculatory disordervaricose veinsatherosclerosisphlebitisdeep vein thrombosis/blood clotsjoint disorder/rheumatoid arthritis/osteoarthritis/tendonitisosteoporosisepilepsyheadaches/migrainescancerdiabetesdecreased sensationback/neck problemsFibromyalgiaTMJcarpal tunnel syndrometennis elbowpregnancyNone
Please explain any conditions you have marked above
Is there anything else about your health history that you think would be useful for your massage practitioner to know to plan a safe and effective massage session for you? If no, please just mark "N/A"*
Clients under the age of 18 must be accompanied by a parent or legal guardian during the entire session. Informed written consent must be provided by parent or legal guardian for any client under the age of 18.
I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage 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 therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so.
Name*

First NameLast Name
Signature*

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Date*

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Date
Informed Consent and Waiver

Massage Client Information & Informed Consent Form
- I understand that massage body workers and holistic practitioners are not medical doctors and do not diagnose illness, disease, or any physical or mental disorder. I acknowledge that massage and alternative holistic therapies are not substitutes for medical treatment, and that Revive and Restore Thrapeutic Massage, LLC, “the company”, recommends I see a primary healthcare provider for that service. I understand that it is my responsibility to communicate with my therapist if I have concerns or questions about my session. I do not have any injuries or conditions that would prevent me from receiving a massage, nor have I been told by a health care provider that I should not receive massages or alternative therapies
- I understand that massage therapy and body work services are a therapeutic health aid and are non‐sexual. I understand my massage therapist reserves the right to end a therapy session in the case of sexual innuendo or advances from the client. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the massage, and I will be liable for full payment of the scheduled session.
- Any information exchanged during a massage or body work session is confidential and is only used to provide me with the best health care services available. I understand that a massage therapist will ask me questions about my health and physical condition and that I am obligated to answer truthfully and honestly about my health history in full detail.
- I understand that my feedback is essential in my treatment, and that if I experience any unusual discomfort and/or pain during my massage session, it is my responsibility to inform the therapist in order to enable the therapist to adjust the pressure or technique being used.
- The therapist reserves the right to decline, discontinue, or restrict services based on any provided information that may indicate that massage therapy would put my health or the therapist’s health at risk.
- I acknowledge that I am responsible to be on time for my appointments and that the therapist is not under any obligation to extend my therapy session. I also agree that I am responsible to pay for the full time I have booked with the therapist if I am late. I understand that my appointment time is reserved for me only. If I miss an appointment or am unable to give twenty four (24) hours’ notice when I need to change or cancel my appointment, I agree to pay the company in full for the booked appointment time.
- I understand that massage therapy and body work are for the purposes of stress reduction, relief from muscular tension, muscular spasm, fascial tension, improving circulation, increasing range of motion.
- I understand that the practitioner does not prescribe medical treatment of pharmaceuticals, nor does he/she perform any spinal manipulations.
- I understand that service offered today, and in the future, are not a substitute for medical care and that any information provided to me by the therapist is purely for educational purposes and is not diagnostically prescriptive in nature.
- I have stated all of my known medical conditions on the Client Intake form. I have consulted a medical doctor or licensed medical health care practitioner regarding any checked or described conditions.
- I understand that it is solely my responsibility to keep the therapist updated on any changes in my physical health and I further understand that the company and the therapist shall not be liable for any purpose and for any reason whatsoever, should I fail to do the needful as per this paragraph.
- I have reviewed this form in its entirety and I have discussed all my concerns regarding my treatment with my therapist
Acknowledgement Section
By signing this “Informed Consent and Wavier”, I consent to receive therapy at Revive and Restore Therapeutic Massage, LLC and hereby agree to all policies of Revive and Restore Therapeutic Massage, LLC, and waive and release Revive and Restore Therapeutic Massage, LLC and its entire staff, massage therapists, and body work practitioners from any and all past, present, and future liability, loss, cost, claim, or damage whatsoever which may be imposed upon the Company relating to massage therapy and body work; including but not limited to, acupressure, all forms of kinesiology, aromatherapy, craniosacral therapy, myofascial release therapy, trigger point therapy, stretching therapy, positional release therapy, strength and condition training, among others. I further undertake to indemnify and hold Revive and Restore Therapeutic Massage, LLC harmless from any incident(s) arising from my use of the Revive and Restore Therapeutic Massage, LLC’s services.
Signature*

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Parent/Guardian Waiver for Minors
If the client is less than 18 years old, the Client’s parent and natural guardian hereby represents that he/she is, in fact, acting in that capacity, has consented to his/her child or ward’s availing of the services of Revive and Restore Therapeutic Massage, LLC, and has agreed individually and on behalf of the child or ward, to the terms of this “Informed Consent and Wavier”. The undersigned parent or guardian further agrees to save and hold harmless and indemnify Revive and Restore Therapeutic Massage, LLC from all liability, loss, cost, claim, or damage whatsoever which may be imposed upon Revive and Restore Therapeutic Massage, LLC relating to massage therapy and body work; including but not limited to acupressure, all forms of kinesiology, aromatherapy, craniosacral therapy, myofascial release therapy, trigger point therapy, stretching therapy, positional release therapy, strength and condition training, among others., on behalf of the Client and all of the Client’s parents or legal guardians.
Signature of Parent/Guardian

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Cancellation, Rescheduling, and Late Arrival Policy
Your appointment is reserved especially for you. The scheduled time reflects when you are expected to be on the table and ready to begin. In order to provide the best possible care for each client and to maintain the smooth operation of my business, the following policies are strictly enforced:

Cancellations & Rescheduling

⦁ Less than 24 Hours’ Notice: Cancellations or rescheduling made with less than 24 hours' notice may result in up to 100% of the service cost being charged, depending on the situation and frequency of cancellations.

Late Arrivals

⦁ Please arrive on time. If you arrive 15 minutes or more late, you will be considered a no-show and charged 100% of the scheduled service.

⦁ If you arrive late but within 15 minutes of your appointment time, your session may be shortened to avoid impacting the next client, but you will still be charged the full session fee.

No-Shows

⦁ Failure to show up without notice will result in a 100% charge of the scheduled service.

⦁ After two (2) no-call/no-show appointments, you will no longer be accepted as a client of Revive and Restore Therapeutic Massage.

⦁ Future appointments after a no-show may require prepayment in full to secure the booking.

This policy exists to protect the time and income of a small, self-run business. Missed or last-minute cancellations can significantly impact my ability to serve clients and sustain my practice. Thank you for your understanding and respect for these guidelines and thank you for choosing me as your massage therapist.
I understand and agree to the Cancellation, Rescheduling, and Late Arrival Policy.
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Revive & Restore

Client Intake Form

The following information will be used to help plan safe and effective massage sessions. Please answer the questions to the best of your knowledge.

Medical History

Clients under the age of 18 must be accompanied by a parent or legal guardian during the entire session. Informed written consent must be provided by parent or legal guardian for any client under the age of 18.

Informed Consent and Waiver

Acknowledgement Section

Parent/Guardian Waiver for Minors

Cancellation, Rescheduling, and Late Arrival Policy

Your appointment is reserved especially for you. The scheduled time reflects when you are expected to be on the table and ready to begin. In order to provide the best possible care for each client and to maintain the smooth operation of my business, the following policies are strictly enforced: