• CLINICAL MASSAGE INTAKE FORM

    Let’s Customize Your Session
  • Client Information

  • Gender*
  • Format: (000) 000-0000.
  • Birthday*
     - -
    2 digit month, 2 digit day, 4 digit year
  • To help us provide the best treatment experience possible, do you have a preference for the gender of your massage therapist? We'll do our best to accommodate your preference based on therapist availability. If we can't, we'll contact you before your appointment or before your session begins.
  • Are you using a gift card or gift certificate today?
  • How would you like to provide your gift card details?
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  • HEALTH HISTORY AND PAIN MANAGEMENT INFORMATION

  • Have you had a professional massage before?*
  • Which type of healthcare professional are you currently seeing?
  • Format: (000) 000-0000.
  • Has your healthcare professional given you any restrictions, precautions, or recommendations that may affect today’s massage?
  • Are you aware of any tension holding spots in your body?
  • Are you currently dealing with ongoing pain or tension?
  • Have you previously experienced soreness, stiffness, increased discomfort, bruising, or another unexpected reaction during or after a massage?*
  • Are you currently receiving care from a licensed healthcare professional for the pain, injury, or condition you would like addressed during your clinical massage?*
  • What type of pain are you experiencing?(Check all that apply)
  • Please mark any areas of pain, tension, swelling, or discomfort.
  • Optional Clinical Massage Enhancements

  • Your therapist can recommend an optional enhancement based on your goals, health history, and today’s assessment. Enhancements are never required and will only be added when appropriate and with your approval.
  • Would you like to explore an optional enhancement for today’s clinical massage?
  • What would you most like your enhancement to support?
  • Which optional enhancement would you like to discuss?
  • SCOPE OF PRACTICE
    Massage therapy is a profession in which the practitioner applies manual techniques, and may apply adjunctive therapies, to positively affect the health and well-being of the client. Massage Therapists do not diagnose or prescribe for medical conditions nor are they allowed to provide treatment for a specific condition without a doctor's supervision. The massage therapist is required to refer you for diagnosis and to follow the recommendations of your physician. The massage therapist is happy to adjust pressure, and table temperature, work longer on an area, or move on if you request it.

    MEDICAL CONDITIONS
    It is the client's responsibility to keep the massage therapist informed of any medical treatment currently being taken, and to provide written permission from the physician, physical therapist, etc., that the massage may be continued. The client must also inform the massage therapist of any changes in health conditions.

    POST-TREATMENT SORENESS & RECOVERY
    Massage therapy is not medical diagnosis or medical treatment. Severe, worsening, unusual, or persistent pain, numbness, weakness, significant swelling, loss of function, difficulty moving, or other concerning symptoms should be evaluated by an appropriate licensed healthcare provider.

    I understand that temporary soreness, tenderness, stiffness, aching, fatigue, or discomfort can occur following clinical massage or bodywork. I understand that these effects can develop after the session, may sometimes persist for several days, and may occur even if I have received massage therapy previously without experiencing these effects. I understand that individual responses to treatment vary.

    CANCELLATION POLICY
    Our goal is to provide quality care in a timely manner. In order to do so, we have had to implement an appointment/cancellation policy. Appointments are in high demand, and your early cancellation will give another person the opportunity to have access to timely care. This policy enables us to better utilize available appointments for our clients.

    If you need to cancel or reschedule your appointment you must call at least 24 hours prior to your appointment, providing less than 24 hours' notice will require you to pay the full-service price as a fee. If you arrive more than 15 minutes late for your appointment without notice it is considered a no-show and you will be charged the full-service price to your card on file.

  • Preferred Therapist (Optional)

  • Important — Tell Us About Your Current Pain

  • Pre-Treatment Pain & Health Acknowledgment*
  • Providing a healthcare professional’s name or contact information does not authorize Somatic Massage Therapy & Spa to contact that professional, request medical records, or disclose your information. A separate written authorization may be required before information is requested or shared.
    • Next: Tell us your goals for today’s session ➜ 
    • This information is collected to help your licensed massage therapist plan a safe and appropriate session. Massage therapists do not provide a medical diagnosis, prescribe medication, or replace evaluation or treatment by a qualified healthcare professional. Please seek appropriate medical care for severe, worsening, unexplained, or concerning symptoms.
    • Is this appointment for Intra-Oral Buccal/TMJ Massage?*
    • Absolute Contraindication Please check all that applies:
    • Show us your pain and discomfort areas:*
    • Our CBD-infused oil may contain trace amounts of THC. Please discuss allergies, sensitivities, pregnancy, medications, workplace drug-testing concerns, or other questions with your therapist before use. Selecting an enhancement only indicates interest. It does not add the service or authorize a charge. Your therapist will confirm that it is appropriate, explain the enhancement, verify the price, and obtain your approval before adding it. If you’re not sure what would be appropriate, your therapist can recommend one appropriate option after reviewing your goals, health history, and any contraindications.
    • Do you have any allergies to oils, lotions, or ointments?*
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    • Consent Form

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    • Today's Date
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      2 digit month, 2 digit day, 4 digit year
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