• Welcome to Luméa Massage

    Thank you for choosing Luméa Massage. Every massage session is thoughtfully personalized to support relaxation, stress relief, muscular wellness, mobility, circulation, and overall well-being. Your comfort, safety, and experience are always our highest priorities. Please complete this intake form thoroughly and honestly. The information you provide allows your therapist to safely customize your massage based on your health history, current wellness needs, treatment goals, and personal preferences. This intake form generally takes 5-10 minutes to complete and is required before your first appointment. Please update your information whenever there are changes to your health, medications, injuries, surgeries, pregnancy status, allergies, or contact information. If you have questions at any time, please ask. Open communication is encouraged before, during, and after every session so your experience can be customized to your comfort. Thank you for allowing Luméa Massage to be part of your wellness journey.
  • CLIENT INFORMATION

  • Format: (000) 000-0000.
  • Date of Birth*
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  • Today's Date*
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  • Which location are you interested in?*
  • Format: (000) 000-0000.
  • BEFORE YOUR SESSION

  • To help create the safest and most relaxing experience possible, please:

    • Complete all required forms before your appointment.

    • Notify your therapist of any changes to your health, medications, injuries, surgeries, pregnancy status, allergies, or other medical conditions before your session.

    • Reschedule your appointment if you have a fever, contagious illness, vomiting, or severe respiratory symptoms.

    • Arrive on time whenever possible.

    • Feel free to ask questions before, during, or after your massage.

    Your therapist will review your health information before your session and customize your massage according to your individual needs and comfort.

  • ABOUT MASSAGE THERAPY

  • Massage therapy is intended to promote relaxation, reduce stress, improve circulation, encourage muscular wellness, support mobility, and enhance overall well-being.

    Massage therapy is not a substitute for medical diagnosis, treatment, or other healthcare services. Your therapist does not diagnose medical conditions, prescribe medications, or perform chiropractic adjustments.

    Every massage is customized according to your health history, comfort level, treatment goals, and your therapist's professional judgment. Techniques, pressure, positioning, draping, session focus, wellness enhancements, and temperature-based therapies may be adjusted at any time to support your comfort and safety.

  • HEALTH HISTORY & MEDICAL SCREENING

  • Your health and safety are our highest priorities. The information you provide helps your therapist customize your massage and determine whether any modifications are needed to provide safe, comfortable, and effective care.

    Please answer all questions honestly and completely. If you are unsure about a medical condition or whether massage is appropriate, please discuss it with your healthcare provider before receiving treatment.

    If your health changes at any time, please notify your therapist before your next appointment.

  • ANNUAL HEALTH UPDATE

  • Have there been any changes since your last massage regarding your health, medications, injuries, surgeries, pregnancy status, allergies, or medical care?
  • RECENT HEALTH CONCERNS

  • Please share any health information or recent conditions that may help your therapist provide safe, personalized, and comfortable care.

     

  • Have you experienced any of the following recently?
  • MEDICAL CONDITIONS

  • Please check any conditions that may affect your massage session. 

  • Cardiovascular & Circulation.
  • Have you recently experienced unexplained swelling, warmth, redness, or pain in the arms or legs?
  • Have you been diagnosed with a blood clot (DVT), pulmonary embolism, or clotting disorder within the past12 months?
  • Musculoskeletal & Nervous System
  • Respiratory
  • Skin & Immune
  • Additional Health Considerations
  • Hormonal & Reproductive/ Pregnancy Status*
  • Allergies & Sensitivities (Please indicate any known allergies, sensitivities, or reactions that may affect your session.)
  • Current Wellness or Medical Care
  • Medications & Wellness Considerations

  • Certain medications or health conditions may influence massage pressure, heat, topical products, or treatment techniques to ensure comfort and safety.

  • Are you currently taking any medications or using topical medical products?*
  • Please check any that apply:
  • Do you bruise easily?
  • Massage Restriction Screening

  • Has a physician or healthcare provider advised you against receiving massage therapy?
  • Heat & Temperature Therapy Screening

  • Do you have reduced sensation, neuropathy, circulation issues, diabetes-related nerve changes, or any condition that may affect your ability to safely perceive heat or cold?
  • YOUR MASSAGE EXPERIENCE

  • Every massage at Luméa Massage is thoughtfully personalized to your needs, comfort level, and wellness goals. The more you share, the more customized your experience can be.

  • Primary reason for today’s visit:
  • Gluteal Area Preference:The gluteal muscles play an important role in supporting the hips, pelvis, and lower back. Would you like your therapist to include the gluteal area as part of your session? (Professional draping will always be maintained. Treatment is performed only within your comfort level and consent. You may dress down to your comfort level)*
  • What type of pressure do you prefer during massage?*
  • Pressure and techniques may always be adjusted throughout your session for comfort.

  • Session Communication Preference*
  • Have you ever received massage therapy before?*
  • Have you ever experienced discomfort or sensitivity following massage therapy?*
  • CUSTOMIZE YOUR WELLNESS EXPERIENCE

  • Would you like a weighted eye pillow during the session?*
  • Upon arrival, would you like the table warmer on?*
  • Special lotion options can be used during your session with no addition cost if you'd like. You can opt out and skip this or choose 1 that can be used on a targeted area of your choice.
  • OPTIONAL WELLNESS ENHANCEMENTS

  • Wellness enhancements may be incorporated into your session to support relaxation, comfort, and overall experience. May be adjusted at any time for comfort and safety.

    Complimentary Enhancements I would enjoy: (Entirely optional and may be enjoyed in any combination. There is no limit to your experience. Choose as many as you wish:

  • Would you enjoy wellness enhancements during your session?*
  • Scalp Ritual
  • Hand Therapy
  • Feet Therapy
  • Heated Stone Therapy
  • Thermal Contrast Therapy (Both Heated Stones and Cool Stones combined throughout session)
  • Aromatherapy Preference
  • WELLNESS ENHANCEMENTS DISCLOSURE

  • Luméa Massage offers a variety of optional wellness enhancements designed to promote relaxation, comfort, circulation, muscular wellness, and an elevated massage experience.

    Enhancements may include aromatherapy, warm towels, heated stones, Himalayan salt stones, thermal contrast therapy (both warm and cool stones), eye pillows, scalp treatments, hand therapy, foot therapy, specialty massage products, and other wellness offerings.

    Please inform your therapist of any allergies, asthma, fragrance sensitivities, migraines, skin conditions, pregnancy, medications, circulation concerns, reduced sensation, or other health conditions that may affect the safe use of these enhancements.

    Some enhancements involve heat, cooling, fragrance, or topical products. Although uncommon, temporary redness, skin sensitivity, irritation, dizziness, headache, nausea, or sensitivity to temperature or fragrance may occur.

    All wellness enhancements are optional and may be modified, discontinued, or declined at any time based on your comfort, health history, personal preference, or your therapist's professional judgment.

    Please notify your therapist immediately if any product, aroma, temperature, pressure, or technique becomes uncomfortable so adjustments can be made right away.

    Wellness enhancements are intended to support relaxation and overall wellness and are not intended to diagnose, treat, cure, or prevent any disease or medical condition.

  • PREMIUM CBD ENHANCEMENT

  • THC-free CBD topical products may be incorporated into your massage session to support relaxation, muscular comfort, and targeted wellness.

    All CBD products used by Luméa Massage are professionally selected topical products intended for external use only.

    Please inform your therapist of any allergies, skin sensitivities, medications, pregnancy, medical conditions, or other concerns that may affect the safe use of CBD products. CBD products may contain plant oils, essential oils, botanical extracts, or other naturally derived ingredients.

    Although uncommon, temporary skin irritation, redness, itching, or sensitivity may occur. A patch test may be offered when appropriate. Please notify your therapist immediately if discomfort occurs so the product may be removed and your treatment adjusted.

    Certificates of Analysis (COAs) verifying THC content and product quality are available upon request.

    CBD products are intended solely as topical wellness products and are not intended to diagnose, treat, cure, or prevent any disease or medical condition.

  • CBD Enhancement Preference*
  • Select your Premium Upgrade of choice.
  • I voluntarily choose to receive a THC-free CBD topical enhancement during my massage session.I acknowledge that I have disclosed any known allergies, sensitivities, pregnancy, medications, medical conditions, or other health concerns that may affect its use.I understand that individual responses to topical CBD products may vary and that I may decline or discontinue CBD use at any time.Except in cases of negligence or willful misconduct, I release Luméa Massage and its therapist from liability arising from the normal use of professionally selected topical CBD products.*
  • PROFESSIONAL MASSAGE POLICIES & INFORMED CONSENT

  • Our goal is to provide every client with a safe, relaxing, respectful, and professional massage experience. Please read the following information carefully.

    Professional Standards
    Massage therapy at Luméa Massage is always professional and non-sexual.

    Respectful communication and professional behavior are expected before, during, and after every appointment. Inappropriate comments, sexual remarks, solicitation, harassment, intimidation, threats, unwanted physical contact, inappropriate exposure, or any behavior that makes your therapist feel unsafe will result in the immediate termination of the session. The full session fee will still apply.

    To maintain the highest standards of safety and professionalism, Luméa Massage may modify, shorten, postpone, refuse, or discontinue services whenever treatment cannot be provided safely, ethically, or within your therapist's professional judgment. 

    Health & Safety
    Please provide accurate and complete health information before every appointment and notify your therapist of any changes to your health, medications, pregnancy status, injuries, surgeries, allergies, illnesses, or medical conditions.

    Massage therapy may be modified, postponed, or declined when treatment is not appropriate or could present a safety concern.

    Massage will not be performed over open wounds, contagious skin conditions, active infections, severe inflammation, or other contraindicated areas.

    If you become ill before your appointment, please contact Luméa Massage to reschedule.

    Massage therapy cannot be provided if you appear impaired or under the influence of alcohol or drugs that may affect your judgment or safety.


    During Your Massage
    Professional draping will be maintained throughout your session. Only the area being treated will be uncovered.

    Please tell your therapist immediately if anything feels uncomfortable, including pressure, positioning, temperature, draping, products, or techniques. Your massage can be adjusted at any time.

    You may request changes or end the session at any time.


    Massage Therapy
    Massage therapy is intended to promote relaxation, reduce stress, improve circulation, encourage muscular wellness, support mobility, and enhance overall well-being.

    Massage therapy is not a substitute for medical diagnosis, medical treatment, chiropractic care, physical therapy, or other healthcare services.

    Your therapist does not diagnose medical conditions, prescribe medications, or perform chiropractic adjustments.

    While many clients experience significant benefits, results vary from person to person and specific outcomes cannot be guaranteed.

    Temporary soreness, tenderness, bruising, redness, fatigue, lightheadedness, dizziness, headache, emotional release, or temporary skin sensitivity may occasionally occur following massage or wellness enhancements.


    Client Responsibilities
    Please:

    • Provide accurate health information.

    • Inform your therapist of any health changes before future appointments.

    • Communicate openly throughout your session.

    • Notify your therapist immediately if you experience pain, numbness, dizziness, excessive heat, cold, discomfort, or any other concern.

    • Follow your therapist's recommendations regarding safety and positioning.

    Client Position Change Responsibility
    When asked to turn over during the session, the client agrees to move slowly and carefully. Client will scoot down as needed, keep their head supported on the table, and turn over at a safe, controlled pace. Client agrees to communicate if they feel dizzy, uncomfortable, unstable, or need assistance before changing positions.


    Our Commitment
    Luméa Massage is committed to providing a personalized, safe, welcoming, and professional wellness experience.

    Your therapist will:

    • Respect your privacy and comfort.

    • Maintain professional draping.

    • Customize your session according to your health history, goals, and preferences.

    • Modify treatment whenever necessary for your safety and comfort.

    • Maintain the confidentiality of your personal information.


    Privacy
    Your personal and health information is used only to provide massage therapy services, maintain client records, communicate regarding appointments, and meet applicable legal or professional obligations.

    Reasonable administrative, physical, and electronic safeguards are used to help protect your information. Information will only be shared with your written authorization, when required by law, or when necessary to protect health or safety.


    Idaho Falls Studio & Driggs Appointments

    To maintain privacy, safety, and the quality of your massage experience, only the scheduled client may be present in the treatment area during the session, unless your therapist has approved an exception in advance. Children may not remain in the treatment area or require your supervision during the session.

    To provide the highest level of care, appointment times are reserved exclusively for you.

    Booking Deposits
    Idaho Falls (First-Time Clients)
    A $15 or $25 non-refundable booking deposit, depending on the service selected, is required to reserve your appointment.

    Driggs Appointments
    A $75 non-refundable booking deposit is required for all appointments.

    Your booking deposit will be applied toward your service total at checkout.

    Rescheduling & Cancellations
    Please provide at least 24 hours' notice if you need to reschedule or cancel your appointment.

    Deposits may be transferred one time to a new appointment when at least 24 hours' notice is provided.
    Appointments canceled with less than 24 hours' notice will forfeit the booking deposit.
    Additional cancellations or reschedules after a courtesy transfer will require a new booking deposit.


    No-Shows
    Clients who do not arrive for their scheduled appointment or fail to notify Luméa Massage before their appointment time will forfeit their booking deposit.

    Refund Policy
    Booking deposits are non-refundable and will be applied toward your scheduled service.

    Massage services that have already been rendered are non-refundable.

    Appointment Policies
    Providing inaccurate health information, refusing to complete required intake forms, arriving under the influence of alcohol or drugs, creating an unsafe environment, or violating professional boundaries may result in cancellation of the appointment, forfeiture of the booking deposit, and/or the full session fee being charged.

    Sessions terminated due to policy violations are non-refundable.

    Clients arriving late may receive a shortened session to avoid delaying other appointments. The full session fee will still apply.


    Personal Property
    Please secure jewelry, valuables, and personal belongings before your session. Luméa Massage is not responsible for lost, stolen, or damaged personal property.


    Photography & Recording
    Photography, video recording, audio recording, livestreaming, or broadcasting during appointments is not permitted without prior mutual consent.


    Emergency Care
    In the unlikely event of a medical emergency, I authorize Luméa Massage to contact emergency medical services (911) and/or my designated emergency contact if my therapist reasonably believes emergency assistance is necessary. I understand that I am responsible for any costs associated with emergency medical care or transportation.

     

    Governing Law
    This agreement shall be interpreted in accordance with the laws applicable in the state where massage therapy services are performed.

     

    Scope of Practice 

    Your massage therapist practices within the professional scope of massage therapy and applicable laws where services are provided. Massage therapy does not include medical diagnosis, prescribing medications, chiropractic adjustments, or other healthcare services outside the massage therapy profession.

    Inclement Weather

    Appointments may be rescheduled due to unsafe travel conditions, severe weather, road closures, or other circumstances affecting safe travel.

     

     

     

     

  • FINAL CLIENT AGREEMENT

  • Thank you for taking the time to complete this intake form.

    By signing below, I acknowledge and agree that:

    • I have read and understand the information contained in this intake form.

    • The information I have provided is true, complete, and accurate to the best of my knowledge.

    • I understand the purpose and limitations of massage therapy.

    • I understand that massage therapy is intended to promote relaxation and overall wellness and is not a substitute for medical diagnosis, treatment, or other healthcare services.

    • I understand that my massage may be modified, postponed, shortened, or declined whenever necessary for safety, medical considerations, or my therapist's professional judgment.

    • I understand that wellness enhancements are optional and may be accepted, modified, or declined at any time.

    • I understand that massage therapy results vary and that specific outcomes cannot be guaranteed.

    • I understand that temporary soreness, tenderness, bruising, fatigue, redness, dizziness, headache, emotional release, or skin sensitivity may occasionally occur.

    • I understand that it is my responsibility to inform my therapist of any changes to my health, medications, injuries, surgeries, pregnancy status, allergies, or other medical conditions before future appointments.

    • I understand that I may ask questions, request modifications, or end my massage session at any time.

    • I understand that my electronic signature has the same legal effect as my handwritten signature.

    • I consent to receive massage therapy services from Luméa Massage.

    I have had the opportunity to ask questions and voluntarily agree to receive massage therapy services under the policies outlined within this intake form.

  • Date*
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  • Thank you for choosing Luméa Massage.

    It is a privilege to be part of your wellness journey. Every session is thoughtfully personalized with your comfort, safety, and well-being in mind.

    We look forward to providing you with a professional, relaxing, and restorative massage experience.

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