Master Client Intake Form

Client Intake Form

Please complete this form prior to your appointment. All information is confidential and collected to support a safe and professional treatment experience.
1. Client Information
Name

First NameLast Name
Preferred Pronouns (optional)
Mobile Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Date of Birth

MonthDayYear
Date
Age
Emergency Contact
Name

First NameLast Name
Relationship
Mobile Number
Please enter a valid phone number.Format: (000) 000-0000.
2. Health & Medical Information

Please answer honestly and to the best of your knowledge.
YesNo
If yes, please specify:
(e.g. oils, lotions, nuts, fruits, skin products)
YesNo
How many months:
Estimated due date:

MonthDayYear
Date
YesNo
If yes, please describe and note the area:
(e.g. rashes, wounds, inflammation)
YesNo
If yes, please describe:
Skin & Cosmetic Treatments

Please answer honestly and to the best of your knowledge.
BotoxDermal fillersChemical / skin peelsMicroneedlingLaser or other advanced skin treatmentsNone of the aboveOther
If yes, please specify treatment(s) and approximate date(s):
Please list any other health conditions, injuries, or concerns that may be relevant to your treatment:
Cancellation & Rescheduling

A minimum of 24 hours’ notice is required to cancel or reschedule an appointment.

Cancellations made with more than 24 hours’ notice are eligible for a full refund or reschedule.

Cancellations made within 24 hours of the scheduled time, or failure to attend a booked appointment (no-show), will be charged in full. Refunds or rescheduling are not available within this timeframe.

Sessions conclude at the scheduled end time. Clients arriving late will receive the remaining session time. Full payment for the scheduled appointment still applies.

If you are unwell, please make contact as soon as possible. Any exceptions to this policy are offered at the practitioner’s discretion.
Professional Boundaries

Vedic Life Ayurvedic Massage is a women-only practice offering professional therapeutic bodywork for relaxation and wellbeing.

All treatments are provided within clear and respectful professional boundaries. Inappropriate behaviour, language, or requests will result in immediate termination of the session, and full payment will still be required.

Clients must not attend appointments under the influence of drugs or alcohol.
Disclaimer & Scope of Practice

I acknowledge that treatments offered by Vedic Life Ayurvedic Massage are intended for relaxation, wellbeing, and supportive care only. They are not a substitute for medical diagnosis, treatment, or cure of any physical or mental health condition.

The therapist does not diagnose, prevent, or treat illness, disease, or injury. If I have any medical concerns or am feeling unwell, I understand it is my responsibility to seek advice from a qualified medical professional.

I accept full responsibility for my health and wellbeing and release Vedic Life and its practitioners from any liability for injury, harm, or adverse effects that may occur during or after a session.
Client Consent & Confirmation
Name

First NameLast Name
Date

MonthDayYear
Date
Signature

Powered by Jotform SignClear
Should be Empty:

Client Intake Form

1. Client Information

Emergency Contact

2. Health & Medical Information

Skin & Cosmetic Treatments