Massage Therapy Client Intake

Massage Therapy Client Intake
Due to COVID-19, we have added a few more questionnaires to the form and updated our Policies and Agreement. All clients (new or current) are required to complete this form prior to service. If you developed any symptoms after completing this form and before your service, please give us a call to reschedule your appointment. The safety of our clients and staff is our top priority.
Full Name*

First NameLast Name
Cell Phone*
Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState

Zip Code
E-mail*
example@example.com
Occupation
Have you ever received a dose of COVID-19 vaccine?

Yes, First DoseYes, Fully VaccinatedNoPrefer not to answer
Have you been tested for COVID-19? If yes, please list when and the result. *
Please check if you are experiencing any of the following as a NEW PATTERN since the beginning of the pandemic:*

FeverChillsCoughSore ThroatDiarrhea, digestive upsetNasal, sinus congestionLoss of sense of taste or smellFatigueShortness of breathSudden onset of muscle soreness (not related to a specific acitivity)Rash or skin lesions (especially on the feet)None of the aboveOther
Reason for Appointment:

Stress ReliefPain ReliefAccident/InjuryGift CertificateOther
What do you want to get out of your session(s)?
Circle areas to Focus on:
Medical History and Information: (Check any or all that apply to your present health.)

AllergiesArthritisAIDS/HIV+Blood ClotsBlood PressureBone InjuryCancerCold or FluDiabetesDisc ProblemHeart DiseaseHeadachesInfectionJoint InjuryOsteoporosisPhlebitisPregnantRecent SurgerySkin ConditionVaricoseOther
If Pregnant, how many weeks pregnant are you
(note: Massage will not be performed if it is in 1st trimester, check our website for other contraindications with pregnancy massage https://farashe.com/policy)
List all current medications:*
List all allergies (medications/lotions/oils/scents/aromatherapy):*
List previous major injuries/surgeries within the last 3 years:*
List physical activities you participate in regularly:
What movements or activities are limited?
What is your main activity at work and/or during the day?

On PhoneSittingComputer WorkWalkingDrivingSportsOther
Where did you find us?*

YelpGoogleFacebook/InstagramFriend's ReferralDirect Mail MarketingOther
Massage Policies:

Client services and chart information are confidential. Written authorization is required from you to release any information.

COVID19 modified spa policy:

• Please wear face mask when entering the spa. No touch temperature check will be conducted at the door and hand sanitizer will be provided.

• Please contact the spa before entering to confirm if the waiting area is available.

       • Please turn off your cell phone or put on slient mode for optimal relaxation

       • Your scheduled session is set aside for you. We do not double book appointments

       • Please reschedule your session if you are more than 15 minutes late

       • 24 hour cancellation notice is required to avoid being charged for your session

       • You will be draped and at no time will genitalia or breast tissue be exposed

       • You will have a consultation with your therapist to discuss your session

       • Should the session require, after your therapist has left the room, you may disrobe to your comfort level

       • I understand that my therapeutic massage therapist or I may end the session at any time for any reason

       • Inappropriate behavior will not be tolerated and may be prosecuted to the full extent of the law

Client Agreement:

I understand that therapeutic massage therapists do not diagnose illness, disease, any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or perform joint mobilization.

I acknowledge that massage therapy is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service.

It is my choice to receive therapeutic massage as a form of therapy.

I understand that treatment given is designed to address the care and prevention of myofascial pain and dysfunction.

I also undersand that at any time I feel pain or discomfort during the session, I will immediately inform my therapeutic massage therapist so they adjust.

I have stated my pertinent medical conditions, and will update the massage therapist of any changes in my health status.

I understand that my failure to do so may post a threat to my health and/physical well being and I hold harmless Farashe The Day Spa and my therapeutic massage therapist from any liability whatsoever arising from failure on my part.

By my electronic signature below, I agree to the massage policy and client agreement above.
Signature*

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