• Simply Zen Massage Therapy

  • CONSULTATION FORM

  • CLIENT INFORMATION:

  • Date of birth:
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  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • MEDICAL HISTORY

  • Please mark any of the following conditions you may currently have.
  • Medical Conditions
  • Any previous surgeries, including plastic surgeries?
  • MASSAGE THERAPY CONSULTATION FORM

  • MASSAGE INFORMATION

  • Do you have any difficulty lying on your front, back or, side?
  • Do you any allergies to oils, lotions, or ointments?
  • Do you have sensitive skin?
  • Have you had a professional massage before?
  • Are there any areas (feet, face, abdomen) you do not want massage?
  • Is there a particular area where you are experiencing tension, pain, or discomfort?
  • What type of massage are you seeking?
  • What pressures do you prefer?
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  • Thank you so much for allowing Simply Zen Massage Therapy to provide your massage today! Below you will find a brief overview of updated policies regarding gift certificates, late arrivals, cancellations, minors, draping/safety, as well as accepted forms of payment.
  • Gift Certificates: Gift certificates are redeemable for the amount indicated on the certificate and must be presented to Casie Jones, LMT, at the beginning of your scheduled appointment. If the gift certificate is unavailable at the time of your appointment, your appointment will be rescheduled. Please take into consideration the 24 hour cancellation policy. Casie Jones, LMT/Simply Zen Massage Therapy is not responsible for lost/stolen gift certificates. Unless specifically stated, gratuity is not included in any gift certificate. Gift certificates, packages and promotions that are expired will not be redeemed.
  • Late Arrivals: If you arrive late, your session may be shortened in order to accommodate others whose appointments follow yours. Depending on how late you arrive, your therapist will then determine if there is enough time remaining to start a session. Regardless of the length of session actually completed, you will be responsible for the "full" scheduled session, this includes package sessions and gift certificates. Out of respect and consideration to your therapist and other customers, please plan accordingly and be on time.
  • Cancellations: 24 Hour Advance Notice Required when cancelling an appointment. If you are unable to give 24 hour advance notice you will be charged the full amount of your scheduled appointment. This amount, including use of package sessions and gift certificates, will be paid/deducted from balance prior to your next appointment. Emergencies happen and will be taken into consideration if you must cancel within 24 hours of your scheduled appointment. The advance notice allows someone else the opportunity to schedule an appointment.
  • Minors: Anyone under 18 years of age must have signed parental approval and the parent must remain in the room throughout the session. There are no exceptions.
  • Draping & Safety: Some sessions (craniosacral and local/distal acupressure) are completed while you remain fully dressed.Should your session include removal of any clothing, you have the right to privacy for undressing and dressing, the massage therapist will not be in the room during this time. For sessions that include removal of any clothing, the draping will be professional and allow for your safety and comfort at all times. Only the area being addressed will be undraped at any time.
  • FOR NO REASON AND AT NO TIME will your breasts or genitals be undraped or exposed, ever. There is no exception. Should you need assistance preparing for your session (undressing, dressing, assistance on/off the massage table) you will need to bring someone to assist you with those things, as your massage therapist cannot.
  • Forms of Payment: Simply Zen Massage Therapy accepts cash or credit/ debit/ Venmo & Cashapp as forms of payment. Checks are not accepted.
  • Massage Therapy

  • CONSENT FORM

  • SCOPE OF PRACTICE

  • The scope of massage therapy encompasses a range of manual techniques and therapeutic approaches used by licensed massage therapists to promote health and well-being. Here are some key aspects of the scope of massage therapy:
    1. Relaxation and Stress Reduction: Massage therapy is widely used to help individuals relax, alleviate stress, and unwind. Techniques such as Swedish massage are particularly effective for this purpose.
    2. Pain Management: Massage can be used to address musculoskeletal pain and discomfort, such as back pain, neck pain, and headaches. Deep tissue massage and trigger point therapy are often employed for pain relief.
    3. Muscle Tension Release: It is used to release muscle tension and spasms, improve flexibility, and enhance muscle function.
    4. Improved Circulation: Massage therapy promotes better blood circulation, aiding in the delivery of oxygen and nutrients to body tissues and the removal of waste products.
    5. Injury Rehabilitation: Massage therapists work with individuals recovering from injuries, surgeries, or sports-related issues to aid in the healing process and improve range of motion.
    6. Sports Massage: This specialized form of massage is used to enhance athletic performance, prevent injuries, and aid in post-event recovery.
    7. Relief from Specific Conditions: Massage therapy can be used as a complementary therapy for certain medical conditions, such as fibromyalgia, arthritis, and chronic pain syndromes.
    8. Relaxation and Wellness: Many people seek massage therapy as part of their overall wellness regimen to maintain physical and mental well-being.
    9. Improved Sleep: Massage can help individuals with sleep issues relax and improve their sleep patterns.
    10. Emotional Well-being: In addition to its physical benefits, massage therapy can have a positive impact on emotional well-being, helping to reduce anxiety and depression.
  • It's important to note that massage therapy is not a replacement for medical treatment, and massage therapists do not diagnose or treat medical conditions. Instead, they work in collaboration with other healthcare professionals to support a client's overall health and well-being.
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  • MASSAGE THERAPY CLIENT CONSENT FORM

  • MEDICAL CONDITIONS

  • It is the client's responsibility to inform the massage therapist of any ongoing medical treatments and to provide written permission from a physician, physical therapist, chiropractor, or other relevant healthcare provider, allowing the massage to proceed. Additionally, the client must promptly inform the massage therapist of any changes in their health conditions. This is crucial for ensuring the safety and appropriateness of the massage therapy session.
  • CONSENT

  • I understand that if I experience any pain or discomfort during the session, it is my responsibility to promptly inform the therapist so that the pressure and stroke may be adjusted to my level of comfort. I further understand that massage therapy should not be regarded as a substitute for a medical examination, diagnosis, or treatment. If I have any physical or mental health concerns, I should seek the advice of a physician or another qualified medical specialist. I will keep the therapist updated on any changes in my medical profile, and I comprehend that the therapist shall not be held liable if I fail to do so. I acknowledge that this is a professional massage session, and any sexual remarks or advances are not appropriate. Such behavior will result in the immediate termination of the session, and I will be responsible for payment of the scheduled treatment. I understand that the massage practitioner reserves the right to refuse services for any reason they deem necessary.
  • By signing below, you agree to the following:

    I have completed this form truthfully and to the best of my knowledge. I agree to waive all liabilities toward my massage therapist and the employer for any injury or damages incurred due to any falsification of my medical history

     

    By signing, I acknowledge that the purpose of massage therapy is to alleviate stress, alleviate muscular tension or spasms, and enhance circulation. I am aware that the massage therapist does not make diagnoses of illnesses, diseases, or any physical or mental disorders. They do not recommend medical treatments or conduct spinal manipulations. I will communicate my current condition to the therapist during each visit.

     

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