Loading...

Massage Client Intake Form

Please read and sign that you understand and agree with the following policies:

CANCELLATION & LATE ARRIVALS

If it is necessary to change your appointment, we request you do so a mininum of 3 hours in advance for an individual appointment or 48 hours in advance for a spa party of 2 people or more. This time is especially reserved just for you and if the appointment is not cancelled, we are not able to offer the time to another guest. Regretfully, if we do not receive the adequate notice of cancellation, a cancellation or a no show fee will be charged to the card on file for each service scheduled ($25 first time and the price of each service scheduled after that). If there is no card on file, the full amount of the missed service will be collected before another appointment can be scheduled. We regret that late arrival for your appointment may deprive you of valuable treatment time. 

CLIENT AGREEMENT

I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any discomfort during this session, I will immediately inform my Practitioner so that the pressure may be adjusted to my level of comfort. I further understand that a Massage Therapist can neither diagnose illness, disease or any other medical, physical, or mental disorder; nor perform any spinal manipulations. I am responsible for consulting a qualified physican for any ailment that I have. Because a Massage Therapist must be aware of any change in my physical health, I understand that there shall be no liability on the Massage Therapist part or Sage Wellness Spa, should I fail to do so. I also understand that any sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.

I hereby acknowledge that I have been provided this notice that the massage service to be received will be provided by Massage Therapists who are independent contractors. I acknowledge that such independent contractors are not employees of Sage Wellness Spa. Therefore, liability, if any, that may arise from the massage service is limited as provided by law. I hereby certify that I am the individual receiving the massage service or a person who is authorized to give consent for the massage service recipient.

RELEASE OF MEDICAL RECORDS

I authorize the release of medical records or other health care information, including intake forms, chart notes, reports, correspondence, billing statements, and other written information to my attorneys, health care providers, and insurance case managers, for the purposes of processing my claims.

COVID-19 AGREEMENT

I knowingly and willingly consent to have massage therapy during the COVID-19 pandemic. I understand that close contact with people increases the risk of infection from COVID-19. I understand that the COVID-19 virus can have a long incubation period, during which carriers of the virus may not show symptoms and can still be highly contagious. I confirm that I am not presenting any of the following symptoms of COVID-19 listed below:

  • Fever temperature over 99.6 F degrees         
  • Chills with or without body aches
  • Shortness of breath
  • New loss of sense or taste or smell
  • Unexplained sores on soles of feet
  • Unsual fatigue
  • Cough
  • Sore throat

Please seek immediate attention if you are displaying any severe signs of COVID-19. I confirm that I have not been in close contact with anyone exhibiting the above COVID-19 symptoms within the past 14 days. I further confirm that I am not currently living with anyone who is sick or who is quarantined. To prevent the spread of contagious viruses and to help protect each other, I understand that I will have to follow the massage therapist's guidelines. I also understand that my name and contact information might be shared with the State Health Department in the event that a client or practitioner at this facility tests positive for COVID-19. My contact details will only be shared in the event they are relevant based on suspected exposure date, and only for appropriate follow-up by the Health Department.

GRATUITY

Many of our clients ask us about appropriate tipping for their services. We hope you find this information helpful. Sage Wellness Spa fee structure for services allows us to provide you with a spa experience for a reasonable cost. We intentionally keep our fees at a lower cost to allow you to properly "tip" your therapist and/or esthetician. Your expression of gratitude is a significant contribution to the income of our therapists and estheticians. An amount of $10-$40 based on the quality and duration of your service is the customary expression of appreciation for the services provided to you.  

Today's Date: April 23, 2024

 

First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Information

How did you hear about us?

Who can we thank for referring you? Please enter first and last name of the client that referred you.

MASSAGE PREFERENCES

Have you had a professional massage before?*
No
Yes

If yes, what types of massage have you had (swedish,deep tissue, hot stone, etc)?

Frequency of massages?
What are your goals for treatment?
Relaxation
Pain Relief
Stress Reduction
What type of pressure do you prefer?
Light
Medium
Deep

CURRENT HEALTH


Reason for initial visit
How would you describe your current stress level?
Low
Medium
High
Very High
Do you exercise regularly and/or participate in any sports?*
No
Yes

If yes, what kind of exercise/sports?
Do you perform any repetitive movement in your work, sports or hobby?*
No
Yes

If yes, describe
Do you sit for long hours at a workstation, computer or driving?*
No
Yes

If yes, describe
Are you experiencing tension, stiffness, discomfort or pain?*
No
Yes

If yes, describe

Please list any major and/or recent injuries, surgeries, or areas of inflammation.

List any medications you are currently taking:
Do you have sensitive skin?*
No
Yes
Do you have any allergies to oils, lotions, ointments?*
No
Yes

If yes, please explain

List any known allergies

DO YOU HAVE ANY OF THE FOLLOWING CONDITIONS? CHECK ALL THAT APPLY.

MUSCULOSKELETAL
Arthritis/Gout
Bone or joint disease
Disk Problems
Jaw Pain (TMJ)
Lupus
Migraines/Headaches
Osteoporosis
Scoliosis
Spinal Problems
Tendonitis/Bursitis
CIRCULATORY
Heart Condition
Phlebitis/Varicose Veins
Blood Clots
High/Low Blood Pressure
Lymphedema
Thrombosis/Embolism
RESPIRATORY
Breathing Difficulty/Asthma
Emphysema
Sinus Problems
Allergies, specify:
NERVOUS SYSTEM
Chronic Pain
Multiple Sclerosis
Numbness/Tingling
Paralysis
Parkinson's Disease
Pinched Nerve
Seizures/Epilepsy
Shingles
SKIN
Athlete's Foot
Cosmetic Surgery
Herpes/Cold Sores
Rashes
Allergies, specify:
DIGESTIVE
Bladder/Kidney Ailment
Colitis
Crohn's Disease
Irritable Bowel Syndrome
Ulcers
PSYCHOLOGICAL
Anxiety/Stress/ptsd
Depression
Fatigue/Sleep Disorder
OTHER
Cancer/Tumors
Diabetes
Drug/Alcohol/Tobacco Use
Contact Lenses
Dentures
Hearing Aids
Broken/Fractured Bones
Bruise easily
Fibromyalgia
Flu/cold symptoms in the last 24 hours
Infectious Disease
Spasms/Cramps
Stroke
Sprains/Strains

Any other medical condition(s) not listed:

Please explain any of the conditions that you have marked above:
Are you pregnant?*
No
Yes

If yes, how many weeks?

Client Agreement

It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my Practitioner of any changes in my health status. 

First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Information

How did you hear about us?

Who can we thank for referring you? Please enter first and last name of the client that referred you.

MASSAGE PREFERENCES

Have you had a professional massage before?*
No
Yes

If yes, what types of massage have you had (swedish,deep tissue, hot stone, etc)?

Frequency of massages?
What are your goals for treatment?
Relaxation
Pain Relief
Stress Reduction
What type of pressure do you prefer?
Light
Medium
Deep

CURRENT HEALTH


Reason for initial visit
How would you describe your current stress level?
Low
Medium
High
Very High
Do you exercise regularly and/or participate in any sports?*
No
Yes

If yes, what kind of exercise/sports?
Do you perform any repetitive movement in your work, sports or hobby?*
No
Yes

If yes, describe
Do you sit for long hours at a workstation, computer or driving?*
No
Yes

If yes, describe
Are you experiencing tension, stiffness, discomfort or pain?*
No
Yes

If yes, describe

Please list any major and/or recent injuries, surgeries, or areas of inflammation.

List any medications you are currently taking:
Do you have sensitive skin?*
No
Yes
Do you have any allergies to oils, lotions, ointments?*
No
Yes

If yes, please explain

List any known allergies

DO YOU HAVE ANY OF THE FOLLOWING CONDITIONS? CHECK ALL THAT APPLY.

MUSCULOSKELETAL
Arthritis/Gout
Bone or joint disease
Disk Problems
Jaw Pain (TMJ)
Lupus
Migraines/Headaches
Osteoporosis
Scoliosis
Spinal Problems
Tendonitis/Bursitis
CIRCULATORY
Heart Condition
Phlebitis/Varicose Veins
Blood Clots
High/Low Blood Pressure
Lymphedema
Thrombosis/Embolism
RESPIRATORY
Breathing Difficulty/Asthma
Emphysema
Sinus Problems
Allergies, specify:
NERVOUS SYSTEM
Chronic Pain
Multiple Sclerosis
Numbness/Tingling
Paralysis
Parkinson's Disease
Pinched Nerve
Seizures/Epilepsy
Shingles
SKIN
Athlete's Foot
Cosmetic Surgery
Herpes/Cold Sores
Rashes
Allergies, specify:
DIGESTIVE
Bladder/Kidney Ailment
Colitis
Crohn's Disease
Irritable Bowel Syndrome
Ulcers
PSYCHOLOGICAL
Anxiety/Stress/ptsd
Depression
Fatigue/Sleep Disorder
OTHER
Cancer/Tumors
Diabetes
Drug/Alcohol/Tobacco Use
Contact Lenses
Dentures
Hearing Aids
Broken/Fractured Bones
Bruise easily
Fibromyalgia
Flu/cold symptoms in the last 24 hours
Infectious Disease
Spasms/Cramps
Stroke
Sprains/Strains

Any other medical condition(s) not listed:

Please explain any of the conditions that you have marked above:
Are you pregnant?*
No
Yes

If yes, how many weeks?

Client Agreement

It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my Practitioner of any changes in my health status. 

Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Information

How did you hear about us?

Who can we thank for referring you? Please enter first and last name of the client that referred you.

MASSAGE PREFERENCES

Have you had a professional massage before?*
No
Yes

If yes, what types of massage have you had (swedish,deep tissue, hot stone, etc)?

Frequency of massages?
What are your goals for treatment?
Relaxation
Pain Relief
Stress Reduction
What type of pressure do you prefer?
Light
Medium
Deep

CURRENT HEALTH


Reason for initial visit
How would you describe your current stress level?
Low
Medium
High
Very High
Do you exercise regularly and/or participate in any sports?*
No
Yes

If yes, what kind of exercise/sports?
Do you perform any repetitive movement in your work, sports or hobby?*
No
Yes

If yes, describe
Do you sit for long hours at a workstation, computer or driving?*
No
Yes

If yes, describe
Are you experiencing tension, stiffness, discomfort or pain?*
No
Yes

If yes, describe

Please list any major and/or recent injuries, surgeries, or areas of inflammation.

List any medications you are currently taking:
Do you have sensitive skin?*
No
Yes
Do you have any allergies to oils, lotions, ointments?*
No
Yes

If yes, please explain

List any known allergies

DO YOU HAVE ANY OF THE FOLLOWING CONDITIONS? CHECK ALL THAT APPLY.

MUSCULOSKELETAL
Arthritis/Gout
Bone or joint disease
Disk Problems
Jaw Pain (TMJ)
Lupus
Migraines/Headaches
Osteoporosis
Scoliosis
Spinal Problems
Tendonitis/Bursitis
CIRCULATORY
Heart Condition
Phlebitis/Varicose Veins
Blood Clots
High/Low Blood Pressure
Lymphedema
Thrombosis/Embolism
RESPIRATORY
Breathing Difficulty/Asthma
Emphysema
Sinus Problems
Allergies, specify:
NERVOUS SYSTEM
Chronic Pain
Multiple Sclerosis
Numbness/Tingling
Paralysis
Parkinson's Disease
Pinched Nerve
Seizures/Epilepsy
Shingles
SKIN
Athlete's Foot
Cosmetic Surgery
Herpes/Cold Sores
Rashes
Allergies, specify:
DIGESTIVE
Bladder/Kidney Ailment
Colitis
Crohn's Disease
Irritable Bowel Syndrome
Ulcers
PSYCHOLOGICAL
Anxiety/Stress/ptsd
Depression
Fatigue/Sleep Disorder
OTHER
Cancer/Tumors
Diabetes
Drug/Alcohol/Tobacco Use
Contact Lenses
Dentures
Hearing Aids
Broken/Fractured Bones
Bruise easily
Fibromyalgia
Flu/cold symptoms in the last 24 hours
Infectious Disease
Spasms/Cramps
Stroke
Sprains/Strains

Any other medical condition(s) not listed:

Please explain any of the conditions that you have marked above:
Are you pregnant?*
No
Yes

If yes, how many weeks?

Client Agreement

It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my Practitioner of any changes in my health status. 

Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Information

How did you hear about us?

Who can we thank for referring you? Please enter first and last name of the client that referred you.

MASSAGE PREFERENCES

Have you had a professional massage before?*
No
Yes

If yes, what types of massage have you had (swedish,deep tissue, hot stone, etc)?

Frequency of massages?
What are your goals for treatment?
Relaxation
Pain Relief
Stress Reduction
What type of pressure do you prefer?
Light
Medium
Deep

CURRENT HEALTH


Reason for initial visit
How would you describe your current stress level?
Low
Medium
High
Very High
Do you exercise regularly and/or participate in any sports?*
No
Yes

If yes, what kind of exercise/sports?
Do you perform any repetitive movement in your work, sports or hobby?*
No
Yes

If yes, describe
Do you sit for long hours at a workstation, computer or driving?*
No
Yes

If yes, describe
Are you experiencing tension, stiffness, discomfort or pain?*
No
Yes

If yes, describe

Please list any major and/or recent injuries, surgeries, or areas of inflammation.

List any medications you are currently taking:
Do you have sensitive skin?*
No
Yes
Do you have any allergies to oils, lotions, ointments?*
No
Yes

If yes, please explain

List any known allergies

DO YOU HAVE ANY OF THE FOLLOWING CONDITIONS? CHECK ALL THAT APPLY.

MUSCULOSKELETAL
Arthritis/Gout
Bone or joint disease
Disk Problems
Jaw Pain (TMJ)
Lupus
Migraines/Headaches
Osteoporosis
Scoliosis
Spinal Problems
Tendonitis/Bursitis
CIRCULATORY
Heart Condition
Phlebitis/Varicose Veins
Blood Clots
High/Low Blood Pressure
Lymphedema
Thrombosis/Embolism
RESPIRATORY
Breathing Difficulty/Asthma
Emphysema
Sinus Problems
Allergies, specify:
NERVOUS SYSTEM
Chronic Pain
Multiple Sclerosis
Numbness/Tingling
Paralysis
Parkinson's Disease
Pinched Nerve
Seizures/Epilepsy
Shingles
SKIN
Athlete's Foot
Cosmetic Surgery
Herpes/Cold Sores
Rashes
Allergies, specify:
DIGESTIVE
Bladder/Kidney Ailment
Colitis
Crohn's Disease
Irritable Bowel Syndrome
Ulcers
PSYCHOLOGICAL
Anxiety/Stress/ptsd
Depression
Fatigue/Sleep Disorder
OTHER
Cancer/Tumors
Diabetes
Drug/Alcohol/Tobacco Use
Contact Lenses
Dentures
Hearing Aids
Broken/Fractured Bones
Bruise easily
Fibromyalgia
Flu/cold symptoms in the last 24 hours
Infectious Disease
Spasms/Cramps
Stroke
Sprains/Strains

Any other medical condition(s) not listed:

Please explain any of the conditions that you have marked above:
Are you pregnant?*
No
Yes

If yes, how many weeks?

Client Agreement

It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my Practitioner of any changes in my health status. 

Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Information

How did you hear about us?

Who can we thank for referring you? Please enter first and last name of the client that referred you.

MASSAGE PREFERENCES

Have you had a professional massage before?*
No
Yes

If yes, what types of massage have you had (swedish,deep tissue, hot stone, etc)?

Frequency of massages?
What are your goals for treatment?
Relaxation
Pain Relief
Stress Reduction
What type of pressure do you prefer?
Light
Medium
Deep

CURRENT HEALTH


Reason for initial visit
How would you describe your current stress level?
Low
Medium
High
Very High
Do you exercise regularly and/or participate in any sports?*
No
Yes

If yes, what kind of exercise/sports?
Do you perform any repetitive movement in your work, sports or hobby?*
No
Yes

If yes, describe
Do you sit for long hours at a workstation, computer or driving?*
No
Yes

If yes, describe
Are you experiencing tension, stiffness, discomfort or pain?*
No
Yes

If yes, describe

Please list any major and/or recent injuries, surgeries, or areas of inflammation.

List any medications you are currently taking:
Do you have sensitive skin?*
No
Yes
Do you have any allergies to oils, lotions, ointments?*
No
Yes

If yes, please explain

List any known allergies

DO YOU HAVE ANY OF THE FOLLOWING CONDITIONS? CHECK ALL THAT APPLY.

MUSCULOSKELETAL
Arthritis/Gout
Bone or joint disease
Disk Problems
Jaw Pain (TMJ)
Lupus
Migraines/Headaches
Osteoporosis
Scoliosis
Spinal Problems
Tendonitis/Bursitis
CIRCULATORY
Heart Condition
Phlebitis/Varicose Veins
Blood Clots
High/Low Blood Pressure
Lymphedema
Thrombosis/Embolism
RESPIRATORY
Breathing Difficulty/Asthma
Emphysema
Sinus Problems
Allergies, specify:
NERVOUS SYSTEM
Chronic Pain
Multiple Sclerosis
Numbness/Tingling
Paralysis
Parkinson's Disease
Pinched Nerve
Seizures/Epilepsy
Shingles
SKIN
Athlete's Foot
Cosmetic Surgery
Herpes/Cold Sores
Rashes
Allergies, specify:
DIGESTIVE
Bladder/Kidney Ailment
Colitis
Crohn's Disease
Irritable Bowel Syndrome
Ulcers
PSYCHOLOGICAL
Anxiety/Stress/ptsd
Depression
Fatigue/Sleep Disorder
OTHER
Cancer/Tumors
Diabetes
Drug/Alcohol/Tobacco Use
Contact Lenses
Dentures
Hearing Aids
Broken/Fractured Bones
Bruise easily
Fibromyalgia
Flu/cold symptoms in the last 24 hours
Infectious Disease
Spasms/Cramps
Stroke
Sprains/Strains

Any other medical condition(s) not listed:

Please explain any of the conditions that you have marked above:
Are you pregnant?*
No
Yes

If yes, how many weeks?

Client Agreement

It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my Practitioner of any changes in my health status. 

Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Information

How did you hear about us?

Who can we thank for referring you? Please enter first and last name of the client that referred you.

MASSAGE PREFERENCES

Have you had a professional massage before?*
No
Yes

If yes, what types of massage have you had (swedish,deep tissue, hot stone, etc)?

Frequency of massages?
What are your goals for treatment?
Relaxation
Pain Relief
Stress Reduction
What type of pressure do you prefer?
Light
Medium
Deep

CURRENT HEALTH


Reason for initial visit
How would you describe your current stress level?
Low
Medium
High
Very High
Do you exercise regularly and/or participate in any sports?*
No
Yes

If yes, what kind of exercise/sports?
Do you perform any repetitive movement in your work, sports or hobby?*
No
Yes

If yes, describe
Do you sit for long hours at a workstation, computer or driving?*
No
Yes

If yes, describe
Are you experiencing tension, stiffness, discomfort or pain?*
No
Yes

If yes, describe

Please list any major and/or recent injuries, surgeries, or areas of inflammation.

List any medications you are currently taking:
Do you have sensitive skin?*
No
Yes
Do you have any allergies to oils, lotions, ointments?*
No
Yes

If yes, please explain

List any known allergies

DO YOU HAVE ANY OF THE FOLLOWING CONDITIONS? CHECK ALL THAT APPLY.

MUSCULOSKELETAL
Arthritis/Gout
Bone or joint disease
Disk Problems
Jaw Pain (TMJ)
Lupus
Migraines/Headaches
Osteoporosis
Scoliosis
Spinal Problems
Tendonitis/Bursitis
CIRCULATORY
Heart Condition
Phlebitis/Varicose Veins
Blood Clots
High/Low Blood Pressure
Lymphedema
Thrombosis/Embolism
RESPIRATORY
Breathing Difficulty/Asthma
Emphysema
Sinus Problems
Allergies, specify:
NERVOUS SYSTEM
Chronic Pain
Multiple Sclerosis
Numbness/Tingling
Paralysis
Parkinson's Disease
Pinched Nerve
Seizures/Epilepsy
Shingles
SKIN
Athlete's Foot
Cosmetic Surgery
Herpes/Cold Sores
Rashes
Allergies, specify:
DIGESTIVE
Bladder/Kidney Ailment
Colitis
Crohn's Disease
Irritable Bowel Syndrome
Ulcers
PSYCHOLOGICAL
Anxiety/Stress/ptsd
Depression
Fatigue/Sleep Disorder
OTHER
Cancer/Tumors
Diabetes
Drug/Alcohol/Tobacco Use
Contact Lenses
Dentures
Hearing Aids
Broken/Fractured Bones
Bruise easily
Fibromyalgia
Flu/cold symptoms in the last 24 hours
Infectious Disease
Spasms/Cramps
Stroke
Sprains/Strains

Any other medical condition(s) not listed:

Please explain any of the conditions that you have marked above:
Are you pregnant?*
No
Yes

If yes, how many weeks?

Client Agreement

It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my Practitioner of any changes in my health status. 

Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Information

How did you hear about us?

Who can we thank for referring you? Please enter first and last name of the client that referred you.

MASSAGE PREFERENCES

Have you had a professional massage before?*
No
Yes

If yes, what types of massage have you had (swedish,deep tissue, hot stone, etc)?

Frequency of massages?
What are your goals for treatment?
Relaxation
Pain Relief
Stress Reduction
What type of pressure do you prefer?
Light
Medium
Deep

CURRENT HEALTH


Reason for initial visit
How would you describe your current stress level?
Low
Medium
High
Very High
Do you exercise regularly and/or participate in any sports?*
No
Yes

If yes, what kind of exercise/sports?
Do you perform any repetitive movement in your work, sports or hobby?*
No
Yes

If yes, describe
Do you sit for long hours at a workstation, computer or driving?*
No
Yes

If yes, describe
Are you experiencing tension, stiffness, discomfort or pain?*
No
Yes

If yes, describe

Please list any major and/or recent injuries, surgeries, or areas of inflammation.

List any medications you are currently taking:
Do you have sensitive skin?*
No
Yes
Do you have any allergies to oils, lotions, ointments?*
No
Yes

If yes, please explain

List any known allergies

DO YOU HAVE ANY OF THE FOLLOWING CONDITIONS? CHECK ALL THAT APPLY.

MUSCULOSKELETAL
Arthritis/Gout
Bone or joint disease
Disk Problems
Jaw Pain (TMJ)
Lupus
Migraines/Headaches
Osteoporosis
Scoliosis
Spinal Problems
Tendonitis/Bursitis
CIRCULATORY
Heart Condition
Phlebitis/Varicose Veins
Blood Clots
High/Low Blood Pressure
Lymphedema
Thrombosis/Embolism
RESPIRATORY
Breathing Difficulty/Asthma
Emphysema
Sinus Problems
Allergies, specify:
NERVOUS SYSTEM
Chronic Pain
Multiple Sclerosis
Numbness/Tingling
Paralysis
Parkinson's Disease
Pinched Nerve
Seizures/Epilepsy
Shingles
SKIN
Athlete's Foot
Cosmetic Surgery
Herpes/Cold Sores
Rashes
Allergies, specify:
DIGESTIVE
Bladder/Kidney Ailment
Colitis
Crohn's Disease
Irritable Bowel Syndrome
Ulcers
PSYCHOLOGICAL
Anxiety/Stress/ptsd
Depression
Fatigue/Sleep Disorder
OTHER
Cancer/Tumors
Diabetes
Drug/Alcohol/Tobacco Use
Contact Lenses
Dentures
Hearing Aids
Broken/Fractured Bones
Bruise easily
Fibromyalgia
Flu/cold symptoms in the last 24 hours
Infectious Disease
Spasms/Cramps
Stroke
Sprains/Strains

Any other medical condition(s) not listed:

Please explain any of the conditions that you have marked above:
Are you pregnant?*
No
Yes

If yes, how many weeks?

Client Agreement

It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my Practitioner of any changes in my health status. 

Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Information

How did you hear about us?

Who can we thank for referring you? Please enter first and last name of the client that referred you.

MASSAGE PREFERENCES

Have you had a professional massage before?*
No
Yes

If yes, what types of massage have you had (swedish,deep tissue, hot stone, etc)?

Frequency of massages?
What are your goals for treatment?
Relaxation
Pain Relief
Stress Reduction
What type of pressure do you prefer?
Light
Medium
Deep

CURRENT HEALTH


Reason for initial visit
How would you describe your current stress level?
Low
Medium
High
Very High
Do you exercise regularly and/or participate in any sports?*
No
Yes

If yes, what kind of exercise/sports?
Do you perform any repetitive movement in your work, sports or hobby?*
No
Yes

If yes, describe
Do you sit for long hours at a workstation, computer or driving?*
No
Yes

If yes, describe
Are you experiencing tension, stiffness, discomfort or pain?*
No
Yes

If yes, describe

Please list any major and/or recent injuries, surgeries, or areas of inflammation.

List any medications you are currently taking:
Do you have sensitive skin?*
No
Yes
Do you have any allergies to oils, lotions, ointments?*
No
Yes

If yes, please explain

List any known allergies

DO YOU HAVE ANY OF THE FOLLOWING CONDITIONS? CHECK ALL THAT APPLY.

MUSCULOSKELETAL
Arthritis/Gout
Bone or joint disease
Disk Problems
Jaw Pain (TMJ)
Lupus
Migraines/Headaches
Osteoporosis
Scoliosis
Spinal Problems
Tendonitis/Bursitis
CIRCULATORY
Heart Condition
Phlebitis/Varicose Veins
Blood Clots
High/Low Blood Pressure
Lymphedema
Thrombosis/Embolism
RESPIRATORY
Breathing Difficulty/Asthma
Emphysema
Sinus Problems
Allergies, specify:
NERVOUS SYSTEM
Chronic Pain
Multiple Sclerosis
Numbness/Tingling
Paralysis
Parkinson's Disease
Pinched Nerve
Seizures/Epilepsy
Shingles
SKIN
Athlete's Foot
Cosmetic Surgery
Herpes/Cold Sores
Rashes
Allergies, specify:
DIGESTIVE
Bladder/Kidney Ailment
Colitis
Crohn's Disease
Irritable Bowel Syndrome
Ulcers
PSYCHOLOGICAL
Anxiety/Stress/ptsd
Depression
Fatigue/Sleep Disorder
OTHER
Cancer/Tumors
Diabetes
Drug/Alcohol/Tobacco Use
Contact Lenses
Dentures
Hearing Aids
Broken/Fractured Bones
Bruise easily
Fibromyalgia
Flu/cold symptoms in the last 24 hours
Infectious Disease
Spasms/Cramps
Stroke
Sprains/Strains

Any other medical condition(s) not listed:

Please explain any of the conditions that you have marked above:
Are you pregnant?*
No
Yes

If yes, how many weeks?

Client Agreement

It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my Practitioner of any changes in my health status. 

Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Information

How did you hear about us?

Who can we thank for referring you? Please enter first and last name of the client that referred you.

MASSAGE PREFERENCES

Have you had a professional massage before?*
No
Yes

If yes, what types of massage have you had (swedish,deep tissue, hot stone, etc)?

Frequency of massages?
What are your goals for treatment?
Relaxation
Pain Relief
Stress Reduction
What type of pressure do you prefer?
Light
Medium
Deep

CURRENT HEALTH


Reason for initial visit
How would you describe your current stress level?
Low
Medium
High
Very High
Do you exercise regularly and/or participate in any sports?*
No
Yes

If yes, what kind of exercise/sports?
Do you perform any repetitive movement in your work, sports or hobby?*
No
Yes

If yes, describe
Do you sit for long hours at a workstation, computer or driving?*
No
Yes

If yes, describe
Are you experiencing tension, stiffness, discomfort or pain?*
No
Yes

If yes, describe

Please list any major and/or recent injuries, surgeries, or areas of inflammation.

List any medications you are currently taking:
Do you have sensitive skin?*
No
Yes
Do you have any allergies to oils, lotions, ointments?*
No
Yes

If yes, please explain

List any known allergies

DO YOU HAVE ANY OF THE FOLLOWING CONDITIONS? CHECK ALL THAT APPLY.

MUSCULOSKELETAL
Arthritis/Gout
Bone or joint disease
Disk Problems
Jaw Pain (TMJ)
Lupus
Migraines/Headaches
Osteoporosis
Scoliosis
Spinal Problems
Tendonitis/Bursitis
CIRCULATORY
Heart Condition
Phlebitis/Varicose Veins
Blood Clots
High/Low Blood Pressure
Lymphedema
Thrombosis/Embolism
RESPIRATORY
Breathing Difficulty/Asthma
Emphysema
Sinus Problems
Allergies, specify:
NERVOUS SYSTEM
Chronic Pain
Multiple Sclerosis
Numbness/Tingling
Paralysis
Parkinson's Disease
Pinched Nerve
Seizures/Epilepsy
Shingles
SKIN
Athlete's Foot
Cosmetic Surgery
Herpes/Cold Sores
Rashes
Allergies, specify:
DIGESTIVE
Bladder/Kidney Ailment
Colitis
Crohn's Disease
Irritable Bowel Syndrome
Ulcers
PSYCHOLOGICAL
Anxiety/Stress/ptsd
Depression
Fatigue/Sleep Disorder
OTHER
Cancer/Tumors
Diabetes
Drug/Alcohol/Tobacco Use
Contact Lenses
Dentures
Hearing Aids
Broken/Fractured Bones
Bruise easily
Fibromyalgia
Flu/cold symptoms in the last 24 hours
Infectious Disease
Spasms/Cramps
Stroke
Sprains/Strains

Any other medical condition(s) not listed:

Please explain any of the conditions that you have marked above:
Are you pregnant?*
No
Yes

If yes, how many weeks?

Client Agreement

It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my Practitioner of any changes in my health status. 

Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Information

How did you hear about us?

Who can we thank for referring you? Please enter first and last name of the client that referred you.

MASSAGE PREFERENCES

Have you had a professional massage before?*
No
Yes

If yes, what types of massage have you had (swedish,deep tissue, hot stone, etc)?

Frequency of massages?
What are your goals for treatment?
Relaxation
Pain Relief
Stress Reduction
What type of pressure do you prefer?
Light
Medium
Deep

CURRENT HEALTH


Reason for initial visit
How would you describe your current stress level?
Low
Medium
High
Very High
Do you exercise regularly and/or participate in any sports?*
No
Yes

If yes, what kind of exercise/sports?
Do you perform any repetitive movement in your work, sports or hobby?*
No
Yes

If yes, describe
Do you sit for long hours at a workstation, computer or driving?*
No
Yes

If yes, describe
Are you experiencing tension, stiffness, discomfort or pain?*
No
Yes

If yes, describe

Please list any major and/or recent injuries, surgeries, or areas of inflammation.

List any medications you are currently taking:
Do you have sensitive skin?*
No
Yes
Do you have any allergies to oils, lotions, ointments?*
No
Yes

If yes, please explain

List any known allergies

DO YOU HAVE ANY OF THE FOLLOWING CONDITIONS? CHECK ALL THAT APPLY.

MUSCULOSKELETAL
Arthritis/Gout
Bone or joint disease
Disk Problems
Jaw Pain (TMJ)
Lupus
Migraines/Headaches
Osteoporosis
Scoliosis
Spinal Problems
Tendonitis/Bursitis
CIRCULATORY
Heart Condition
Phlebitis/Varicose Veins
Blood Clots
High/Low Blood Pressure
Lymphedema
Thrombosis/Embolism
RESPIRATORY
Breathing Difficulty/Asthma
Emphysema
Sinus Problems
Allergies, specify:
NERVOUS SYSTEM
Chronic Pain
Multiple Sclerosis
Numbness/Tingling
Paralysis
Parkinson's Disease
Pinched Nerve
Seizures/Epilepsy
Shingles
SKIN
Athlete's Foot
Cosmetic Surgery
Herpes/Cold Sores
Rashes
Allergies, specify:
DIGESTIVE
Bladder/Kidney Ailment
Colitis
Crohn's Disease
Irritable Bowel Syndrome
Ulcers
PSYCHOLOGICAL
Anxiety/Stress/ptsd
Depression
Fatigue/Sleep Disorder
OTHER
Cancer/Tumors
Diabetes
Drug/Alcohol/Tobacco Use
Contact Lenses
Dentures
Hearing Aids
Broken/Fractured Bones
Bruise easily
Fibromyalgia
Flu/cold symptoms in the last 24 hours
Infectious Disease
Spasms/Cramps
Stroke
Sprains/Strains

Any other medical condition(s) not listed:

Please explain any of the conditions that you have marked above:
Are you pregnant?*
No
Yes

If yes, how many weeks?

Client Agreement

It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my Practitioner of any changes in my health status. 

Client's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

How did you hear about us?

Who can we thank for referring you? Please enter first and last name of the client that referred you.

MASSAGE PREFERENCES

Have you had a professional massage before?*
No
Yes

If yes, what types of massage have you had (swedish,deep tissue, hot stone, etc)?

Frequency of massages?
What are your goals for treatment?
Relaxation
Pain Relief
Stress Reduction
What type of pressure do you prefer?
Light
Medium
Deep

CURRENT HEALTH


Reason for initial visit
How would you describe your current stress level?
Low
Medium
High
Very High
Do you exercise regularly and/or participate in any sports?*
No
Yes

If yes, what kind of exercise/sports?
Do you perform any repetitive movement in your work, sports or hobby?*
No
Yes

If yes, describe
Do you sit for long hours at a workstation, computer or driving?*
No
Yes

If yes, describe
Are you experiencing tension, stiffness, discomfort or pain?*
No
Yes

If yes, describe

Please list any major and/or recent injuries, surgeries, or areas of inflammation.

List any medications you are currently taking:
Do you have sensitive skin?*
No
Yes
Do you have any allergies to oils, lotions, ointments?*
No
Yes

If yes, please explain

List any known allergies

DO YOU HAVE ANY OF THE FOLLOWING CONDITIONS? CHECK ALL THAT APPLY.

MUSCULOSKELETAL
Arthritis/Gout
Bone or joint disease
Disk Problems
Jaw Pain (TMJ)
Lupus
Migraines/Headaches
Osteoporosis
Scoliosis
Spinal Problems
Tendonitis/Bursitis
CIRCULATORY
Heart Condition
Phlebitis/Varicose Veins
Blood Clots
High/Low Blood Pressure
Lymphedema
Thrombosis/Embolism
RESPIRATORY
Breathing Difficulty/Asthma
Emphysema
Sinus Problems
Allergies, specify:
NERVOUS SYSTEM
Chronic Pain
Multiple Sclerosis
Numbness/Tingling
Paralysis
Parkinson's Disease
Pinched Nerve
Seizures/Epilepsy
Shingles
SKIN
Athlete's Foot
Cosmetic Surgery
Herpes/Cold Sores
Rashes
Allergies, specify:
DIGESTIVE
Bladder/Kidney Ailment
Colitis
Crohn's Disease
Irritable Bowel Syndrome
Ulcers
PSYCHOLOGICAL
Anxiety/Stress/ptsd
Depression
Fatigue/Sleep Disorder
OTHER
Cancer/Tumors
Diabetes
Drug/Alcohol/Tobacco Use
Contact Lenses
Dentures
Hearing Aids
Broken/Fractured Bones
Bruise easily
Fibromyalgia
Flu/cold symptoms in the last 24 hours
Infectious Disease
Spasms/Cramps
Stroke
Sprains/Strains

Any other medical condition(s) not listed:

Please explain any of the conditions that you have marked above:
Are you pregnant?*
No
Yes

If yes, how many weeks?

Client Agreement

It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my Practitioner of any changes in my health status. 

Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!