Therapeutic Hands ~ Client Intake and Consent Form

Client Confidential Intake and Consent Form For Therapeutic Services with Angela Lind. Licensed Massage Therapist.

Lic#MA45645

www.Therapeutic-Hands.com
Full Name*

First NameMiddle NameLast Name
Address (where services will be provided)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
Mobile Phone preferred
This is my:*
E-mail*

Confirmation Email
Medications
Prescribed or over the counter.
Do you have any allergies and/or skin sensitivities?
Allergies to nut or almond products? Allergic to oils, lotions or scents?
Reason to receive therapy*

Relaxation/Stress ReliefPain Relief/Muscle Tension ReliefLymphedema ManagementLymphatic Drainage (non-surgical related)Post-Surgical Lymphatic DrainageLipedema ManagementOther
Medical conditions in the past or recent, please check all that apply from the list below:

StrokeDeep Vein Thrombosis/Blood ClotsCardiac Issues (Heart attack, congenital heart failure, etc.)Spinal condition (scoliosis, kyphosis, lordosis, herniated disc, etc).Bruise easilyVaricose veinsDiabetesFibromyalgiaCancerJoint disorderRenal FailureSkin diseaseSevere osteoporosisSevere thrombocytopeniaFracturesAsthmaHigh blood pressureHeavy smokerOther
Besides the lists above, have you had in the past any surgeries, injuries or limitations that I need to be aware of? or is there anything that you think is relevant or would be useful for the therapist to know for your session?
Have you had in the last weeks the following symptoms? Please check all that apply from the list below:

FeverDry CoughFatigueDifficulty breathingLoss of taste and smellHeadachesChest painSore throatOther
Consent is required to each part of the body. Please indicate which areas would you like to give consent in every session provided by Angela Lind. Check all that apply*

Head/ScalpFaceNeckBackChestAbdomenArmsLegsGlutes/ButtocksFeet
My service is strictly mobile. For logistic purposes, can you provide information of the parking availability when I arrive at your place? *

I live in a single-family home/townhouse and you can park in my drivewayI live in a townhouse residential community with visitor parkingI live in an apartment/condo building with visitor parkingI live in an apartment/condo building with only valet parkingI'm in a vacation rental building with free self-parking lotOther
Do I need to climb stairs to get to your place? (Whether outside your building or inside your house/condo where the massage table will be set up)*

YesNoOther
*Please note:

Appointments will be canceled on days with bad weather conditions, severe flooding, and storms.

Face masks are no longer worn by the therapist. Clients do not need to wear a face mask during their sessions.

Receiving a massage when you are sick is not advised. While in the early and acute stages of a cold, flu, fever, or other illness, a massage can accelerate the onset of the infection and intensify its severity. If you or your household members have experienced flu symptoms, cold symptoms, or coronavirus-Covid19 symptoms within the last 14 days, please wait until you have been well for at least two weeks before getting your massage.

For your well-being as well as the health of the therapist and other clients, please reschedule your appointment if you have symptoms associated with coronavirus, cold, flu, or other contagious diseases such as chickenpox, measles, thrush, impetigo, herpes, etc. Thank you.*
Massage Policies:

• To ensure the optimal treatment experience, enough space for setting up the table and moving around the table, with a minimum space of 10 feet x 8 feet is required.

• Additionally, it's required that the indoor temperature is 73°F or below, along with indoor air being smoke-free from cigarettes, marijuana, incense, or any type of smoke. Your cooperation in ensuring a comfortable and healthy environment is greatly appreciated.

• Massage is strictly ethical and professional. Full draping is a must and not an option. Any verbal or physical conduct of a sexual nature, including flirting, will constitute sexual harassment and will not be tolerated.

Client Agreement:

I understand that close contact with people increases the risk of infection from COVID-19. By signing this form, I acknowledge that I'm aware of the risks involved and give consent to receive a massage from this practitioner.

I acknowledge that my massage therapist does not diagnose or prescribe medical treatment.

I understand that massage therapy is not a substitute for medical examination and I may need to see a physician for medical concerns.

I choose to receive massage and lymphatic drainage as therapy.

I am aware that my insurance does not cover these services and I am responsible for payment.

I will communicate any pain or discomfort during the session to my therapist.

I have provided accurate medical information and will update my therapist on any changes.

I consent to receive therapy and understand the risks of not doing so.

I release my therapist from liability for any health or well-being issues resulting from my failure to follow these guidelines.

I understand that inappropriate behavior may result in the termination of the session and full payment will be required.

I have read or have read to me the above consent.

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

Clear
Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.
Should be Empty: