• Client intake form

  • Contact

  • DOB
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Medical Information

  • Are you currently under a Physicians Care?
  • Are you taking any Medications?
  • Are you currently pregnant?
  • Please check any of the following health issues that you currently have or had in the past year?*
  • Massage Information

  • Have you ever had a professional massage before?
  • What type of massage are you seeking?
  • Do you have any allergies or sensitivities?
  • Please Indicate the areas of your body where you are feeling discomfort.
  • TERMS, POLICIES & INFORMED CONSENTS

    •Scope of Practice: I understand that massage therapy is provided for stress reduction, relief from muscular tension, spasm, or pain, and for increasing circulation. I clearly understand that massage therapists do not diagnose illness, disease, or any other physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or perform spinal manipulations. I acknowledge that massage therapy is not a substitute for medical examination, diagnosis, or treatment.

    •Client Responsibility: I state that I have answered all health questions honestly and completely. I agree to update the therapist regarding any changes in my health profile during future sessions. I understand that sitting or lying in one position for an extended time may carry minor risks, and I will communicate any discomfort immediately.

    •Draping Policy: I understand that professional, therapeutic draping is required at all times. Only the specific area of the body being worked on will be uncovered.

    •Cancellation & Late Policy: I agree to provide at least 24 hours' notice for cancellations. I understand that late arrivals will result in a shortened session time to accommodate subsequent appointments, and full payment will still be required.

    •Right of Refusal: I acknowledge that this environment is strictly professional and safe. Any illicit, aggressive, or sexually suggestive remarks or behavior will result in the immediate termination of the session, and I will remain responsible for full payment. The therapist also reserves the right to refuse service if a medical condition makes treatment unsafe.

    ACKNOWLEDGMENT & SIGNATURE by signing below, I agree to the terms above and give my informed consent to receive massage therapy treatment.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Bella Guevara

    Certified Massage Therapist 

    CAMTC ID:103406

    Text: (818) 278-4028

    Email: theravivemassage@gmail.com

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