Intake, Consent, & Benefits Information
The information collected in this form will be used only to design an appropriate massage therapy program for you. It will not be disclosed to any third party without your consent.
GENERAL INFORMATION
Name
*
First Name
Last Name
Email
*
example@example.com
Preferred name (if different, so your therapist can address you appropriately)
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Occupation
*
How did you hear about us?
Please Select
Google
Social Media
Website
Street signs
Flyers
Client referral
Other
If referral, please enter the name of the person who referred you:
If other, please indicate:
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
MASSAGE INFORMATION
Do you have any allergies or sensitivities to scents, nuts, oils, ointments, or lotions? If yes, please explain:
What pressure do you prefer?
*
Light
Medium
Deep
What is your primary concern for seeking a treatment today?
*
What repetitive movements do you perform with hobbies or at work?
*
When was your most recent massage treatment?
*
Which treatments have you received so far for this concern? (Select all that apply.)
*
Physiotherapy
Chiropractic care
Medical doctor / physician care / neurologist
Acupuncture
Massage Therapy
Other
Are there any areas of your body that you do NOT want to be treated?
Please choose your preference below:
*
I like to talk.
Moderate (I prefer not to talk the entire time, but I can discuss issues about my health and physics).
Quiet massage.
Other
MEDICAL INFORMATION
*
If pregnant, please indicate how many weeks pregnant. Prenatal massage is available once you are at least 12 weeks (3 months) pregnant.
Please list any medications you currently take (prescription or over-the-counter) that may affect your massage treatment (e.g., blood thinners, pain relievers, anti-inflammatories, muscle relaxants):
ARE THERE ANY OTHER HEALTH CONDITIONS THAT I NEED TO BE AWARE OF?
*
Yes.
No.
If yes, please explain:
Please add anything you feel is important we should know:
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Informed Consent
Minors (Under 18): A parent/legal guardian must provide consent for clients under 18 and may be required to be present, per clinic policy.
General Consent: I acknowledge that Masahista Healing Hands provides Massage Therapy and related services, which may include variations of Cupping Therapy, Hot Stone Massage, Thai Massage, Reflexology, and other therapies offered by the clinic. Services are provided by licensed and/or registered practitioners.
*
I agree.
Benefits & Possible Effects: I understand massage and related therapies may provide benefits such as relaxation, relief of muscular tension, and reduced stress-related symptoms; however, results are not guaranteed. I understand temporary effects may occur, including increased awareness of discomfort, muscle soreness, light-headedness/dizziness, and mild bruising.
*
I agree.
Client Communication During Treatment: I understand it is my responsibility to inform the therapist immediately of any discomfort, pain, or concerns during treatment so adjustments can be made.
*
I agree.
Scope of Practice: I understand massage therapy is not a substitute for medical care. The therapist does not diagnose medical conditions, prescribe medications, or perform spinal manipulation. I may ask questions at any time and request an explanation of any technique or procedure used.
*
I agree.
Sensitive Areas (if clinically indicated): I consent to assessment and massage of the following areas: gluteal/hip area, abdomen, upper chest/pectoral area (excluding breast tissue), and upper inner thigh/adductors. The therapist will maintain professional draping, explain the clinical reason, and check in before starting.
*
I agree.
Specialty Services Consents
(agree only if applicable)
Student Massage (if selected): I understand and agree that treatment may differ from an RMT massage (pace/technique) due to training, and will be provided by a first- or second-year student therapist under clinic supervision.
I agree.
Prenatal Massage (if selected): I confirm I am pregnant and have disclosed my stage of pregnancy and any relevant health concerns. I understand prenatal massage uses modified positioning/techniques and generally avoids direct abdominal massage. If I have a high-risk pregnancy or have been advised to avoid massage, I will obtain medical clearance before treatment.
I agree.
Cupping / Fire Cupping (if selected): I understand cupping (static or moving) may cause temporary circular marks/discoloration, redness, and soreness/tenderness that may last several days (sometimes longer). In uncommon cases, skin irritation or blistering may occur. For Fire Cupping, I understand brief use of flame is used to create suction and there is a small risk of burn.
I agree.
Hot Stone Massage (if selected): I understand Hot Stone Massage uses heated stones applied to the body and may cause temporary warmth, redness, and soreness. I understand heat tolerance varies, and I will tell the therapist immediately if the stones feel too hot or uncomfortable so they can adjust or remove them. I understand there is a small risk of skin irritation or burn.
I agree.
Thai Massage (if selected: Thai Oil / Traditional Thai / Thai No Oil): I understand Thai massage may include firm pressure/compression and assisted stretching (with or without oil/lotion, and may be done fully clothed for Traditional Thai). Temporary effects may include soreness, stretching discomfort, and occasional mild bruising. I will inform the therapist of any injuries, pain, medical conditions, or movement limits so pressure and stretching can be modified.
I agree.
Home Service/Mobile Massage (if selected): I understand this appointment is provided off-site (e.g., home/hotel/workplace). I agree to provide a safe, clean, and private space with adequate room for the massage table, and to secure pets and minimize interruptions. I understand the therapist may end the session if safety, appropriate conduct, or the environment is not suitable.
I agree.
Professional Conduct
Zero Tolerance Policy: I understand that sexually suggestive comments, requests, or advances are strictly prohibited. In the event of inappropriate conduct, the therapist may end the session immediately and the full scheduled fee will apply.
*
I agree.
Appointment Guidelines
(Cancellation, No-Show & Late Arrival)
Late Cancellation & No-Show Policy: I agree to provide at least 12 hours’ notice before my scheduled start time to cancel or reschedule. Cancellations/reschedules with less than 12 hours’ notice, or missed appointments (“no-shows”), are subject to a $40 fee.
*
I agree.
Late Arrival Policy: I understand I should arrive 5–15 minutes before my scheduled start time. My scheduled appointment time is my hands-on treatment time, and arriving early allows time for intake/assessment so treatment can begin on time. If I arrive late, my session will still end at the scheduled end time to avoid delaying other clients. I understand I may receive less treatment time and will be responsible for the full service fee.
*
I agree.
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Insurance Information
Primary Insurance
*
Yes
No
Policy Holder's Name
*
Policy holder’s date of birth:
*
-
Month
-
Day
Year
Date
Your insurance company/carrier:
*
Group, policy, or contract number:
*
Certificate or Member ID number:
*
Division ID (Empire Life only)
Client Relationship to Member
*
Please Select
Insured member
Spouse
Child
Handicapped dependent
Part time student
Full time student
Domestic partner
Secondary Insurance (if applicable)
*
Yes
No
Policy holder’s name:
*
Policy holder’s date of birth:
*
-
Month
-
Day
Year
Date
Your insurance company/carrier:
*
Group, policy, or contract number:
*
Certificate or Member ID number:
*
Division ID (Empire Life only)
Client Relationship to Member
*
Please Select
Insured member
Spouse
Child
Handicapped dependent
Part time student
Full time student
Domestic partner
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Insurance and Direct Billing Authorization
If I choose to provide insurance information (Primary and/or Secondary), I understand it is used to help submit benefit claims and/or attempt direct billing where available. I understand coverage and payment are determined by my insurer and are not guaranteed.
Consent to Collect, Use, and Disclose Information for Insurance Claims: I authorize Masahista Healing Hands to collect, use, and disclose my personal information (and health information where required) and any plan member/policy holder information I provide (e.g., name, date of birth, insurer/carrier, group/policy number, certificate/ID number, relationship) for the purpose of verifying benefits (where applicable) and submitting, assessing, administering, auditing, and investigating insurance claims, including the prevention/investigation of fraud or plan abuse. This information may be disclosed to my insurer/plan administrator and their service providers for these purposes. If I am not the plan member/policy holder, I confirm I have their permission to provide their information and to authorize claim submission for the purposes stated above.
*
I agree.
Direct Billing Authorization and Payment Responsibility: If direct billing is attempted, I authorize Masahista Healing Hands to submit claims to my Primary insurer and, if applicable, my Secondary insurer. I understand I am responsible for all fees not covered or not paid by my insurer(s), or if payment is not made directly to the provider, and I agree to pay any balance owing.
*
I agree.
Card on File: If I have provided a payment method, I authorize the clinic to securely store it and charge any outstanding balance related to this appointment/claim if an amount remains owing after insurance processing.
*
I agree.
Marketing Consent
(optional)
I agree to receive e-mail marketing and promotional communications from Masahista Healing Hands. I understand I can unsubscribe at any time.
*
Yes.
No.
I consent to Masahista Healing Hands sharing my email/phone with its marketing agency and ad platforms for audience matching/ad measurement (may be hashed). I can withdraw consent at any time.
*
Yes.
No.
Digital Signature (Typed Full Name) If the client is under 18, a parent/legal guardian must type their full name here.
*
Today's Date
*
-
Month
-
Day
Year
Date
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