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In WA state, I am a healthcare professional and for your safety, the following fields are to be filled out completely and truthfully.

*Minors will need this intake completed by a parent/guardian. A minor release form will also need to be signed in person by the parent/guardian. 

BY SIGNING BELOW, YOU AGREE TO THE FOLLOWING:

I give my permission to receive massage therapy. I understand therapeutic massage is not a substitute for traditional medical treatment or medications and that the massage therapist does not diagnose illnesses and injuries or prescribe medications. And I have clearance from my physician to receive massage therapy.

I understand the risks associated with massage therapy (such as cupping, gua sha, Ashiatsu, hot stones, deep tissue, etc.) include, but are not limited to: superficial bruising, short-term muscle soreness, burns, & exacerbation of undiscovered injury. As well as any miscarriages, early labor, and other pregnancy complications from prenatal massage. I therefore release Vita Nova Massage and Antonietta Ramirez, LMT from all liability concerning these injuries that may occur during the massage session.

I understand the importance of informing my massage therapist of all medical conditions, allergies, and medications I am taking, and to let the massage therapist know about any changes to these. I understand there may be additional risks based on my physical condition.

I understand that it is my responsibility to inform my massage therapist of any discomfort I may feel during the massage session, so she may adjust accordingly.

I understand that I or the massage therapist may terminate the session at any time. I understand that throughout the session, the therapist will always use a drape, meaning a blanket and sheet.

I also understand that my massage therapist does not massage genitals or perform perineal massage (massaging the tissues between the anus and genitals) and that any illicit or sexual innuendos or advances will result in termination of the session and that I am liable for full payment of the session. I also understand that my therapist does not date her clients and that I will not contact my massage therapist via text, phone, or email with conversation or questions regarding her personal life.

I understand that all communication between I the client and the therapist in any sessions, phone calls, texts, letters, or e-mails is confidential within the constraints of the law. This also applies to any session documentation and intake forms which will always be secured. I give permission for the therapist to contact my emergency contact(s) in case of an emergency.

Please select who will be receiving massage therapy...
AdultMinor
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First Client's Name

First Name*

Middle Name

Last Name*

Phone*
First Client's Date of Birth*
First Client's Intake (Use "n/a" for no response)

Please list any health conditions, recent surgeries, and medications that could be affected by massage therapy. If you are currently pregnant, please describe here. *

Please list any allergies/sensitivities: (Such as essential oils, avocado, mango, coconut oil, shea nut oil, arnica, etc.) *

Please list any areas to avoid: (Such as the face, scalp, feet) *

Please describe any goals for your session and what type of massage you're looking for. Is it mainly relaxation, treatment, or a combination of the two? If you know certain modalities that you like, please list them here, such as cupping, gua sha, deep tissue, ashiatsu, Swedish, etc. *

Pressure Preference: Do you have a high pain tolerance and want very firm to deep pressure or light-medium? Or do you prefer light pressure on your legs and firmer pressure on your back, etc. If you're not sure, don't worry, we'll figure it out during the session. *

Areas to focus on (specifically chronic): Please note, if you have many problem areas and still want a full body massage, I would recommend a 90 minute or 120 minute session. *
Do you want chest massage (not including breast tissue)? *
No
Do you want the work under the sheet "skin to skin contact"?
Do you want the work over the sheet?
Do you want your glutes/hips massaged? *
No
Do you want the work under the sheet "skin to skin contact"?
Do you want the work over the sheet?
Do you want your adductors "inner thighs" massaged? *
No
Do you want the work under the sheet "skin to skin contact"?
Do you want the work over the sheet?
Do you want abdominal massage? *
No
Do you want the work under the sheet "skin to skin contact"?
Do you want the work over the sheet?
I am not trained to perform breast work, but you have the option to leave your breasts uncovered. This question applies to all genders. *
keep breasts covered throughout the session
keep breasts uncovered throughout the session
keep breasts covered during chest work
keep breasts uncovered during chest work
keep breasts covered during abdominal work
keep breasts uncovered during abdominal work
First Client's Signature*
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

Emergency Contact's 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.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Intake (Use "n/a" for no response)

Please list any health conditions, recent surgeries, and medications that could be affected by massage therapy. If you are currently pregnant, please describe here. *

Please list any allergies/sensitivities: (Such as essential oils, avocado, mango, coconut oil, shea nut oil, arnica, etc.) *

Please list any areas to avoid: (Such as the face, scalp, feet) *

Please describe any goals for your session and what type of massage you're looking for. Is it mainly relaxation, treatment, or a combination of the two? If you know certain modalities that you like, please list them here, such as cupping, gua sha, deep tissue, ashiatsu, Swedish, etc. *

Pressure Preference: Do you have a high pain tolerance and want very firm to deep pressure or light-medium? Or do you prefer light pressure on your legs and firmer pressure on your back, etc. If you're not sure, don't worry, we'll figure it out during the session. *

Areas to focus on (specifically chronic): Please note, if you have many problem areas and still want a full body massage, I would recommend a 90 minute or 120 minute session. *
Do you want chest massage (not including breast tissue)? *
No
Do you want the work under the sheet "skin to skin contact"?
Do you want the work over the sheet?
Do you want your glutes/hips massaged? *
No
Do you want the work under the sheet "skin to skin contact"?
Do you want the work over the sheet?
Do you want your adductors "inner thighs" massaged? *
No
Do you want the work under the sheet "skin to skin contact"?
Do you want the work over the sheet?
Do you want abdominal massage? *
No
Do you want the work under the sheet "skin to skin contact"?
Do you want the work over the sheet?
I am not trained to perform breast work, but you have the option to leave your breasts uncovered. This question applies to all genders. *
keep breasts covered throughout the session
keep breasts uncovered throughout the session
keep breasts covered during chest work
keep breasts uncovered during chest work
keep breasts covered during abdominal work
keep breasts uncovered during abdominal work
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.


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