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LOCATIONS:

 

150 S Pacific Coast Hwy # F,  El Segundo CA 90245

310-414-3006

 

8329 Lincoln Blvd, Los Angeles CA 90045 

310-568-0941

This record of consent is required before the first assessment or treatment and will be maintained confidentially in the client file. It may only be released to a third party with prior written consent of the client.
Massage Therapy includes the assessment and treatment of the soft tissues and joints of the body, using soft tissue manipulation, joint mobilization.
By signing below, the client agrees to the following:
All massage treatments, information and records will be kept confidential and securely stored for use only by my massage therapist.
Written consent must be given by me prior to any disclosure or sharing of my personal and clinical information with any third party, unless subpoena is handed.
Privacy will be assured as I have the right to undress only to my comfort level and according to the requirements of the treatment.
Draping will be used by the therapist as required to expose only those parts of my body that require treatment and/or as I choose to ensure my comfort during treatment.
If at any time during the treatment, I feel uncomfortable with the treatment for any reason, I have the right to request an immediate stop to the session or request modifications to the treatment, regardless of prior consent given. If massage is stopped on the first 15 minutes no charge will apply, if even I dislike the service but received it in full fees will be due as expected.
Promptness is expected for all appointments. In the event of lateness, the massage may be cut short due to the therapist other commitments. Fees will be maintained per the schedule.
Cancellation of any appointment must be received at least 24 hours in advance. No show or last minute cancelation will be liable to full fee payment.
Fees for treatment are due prior to departure on the day of the treatment. Cash or credit cards are accepted.
The therapist may refuse to treat any client or part of their body with just and reasonable cause.

First Client's Name

First Name*

Middle Name

Last Name*

Phone*
First Client's Date of Birth*
First Client's Health History
Have you ever received professional massage/bodywork before?*
No
Yes

How recently?
What kind of pressure do you prefer?*
Light
Medium
Firm
Combo
Do you currently have any condition?
Pregnancy
Cancer
Broken Bones
Hearth Condition
Surgeries
Other
None

List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):
Do these symptoms interfere with your activities of daily living (e.g., sleep, exercise, work, childcare)?*
No
Yes
N/A
Have you had any injuries or surgeries in the past that may influence today's treatment? Choose any of the following health conditions that you currently have. Please answer honestly, as massage may not be indicated for the following conditions.
Blood Cloths
Infections
Flu/Fever
Congestive Heart Failure
Contagious Diseases
Pitted Edema
None
Please indicate conditions that you have or have had in the past.
Muscle or joint pain
Muscle or joint stiffness
Numbness or tingling
Swelling
Bruise easily
Sensitive to touch/pressure
High/Low blood pressure
Stroke, heart attack
Varicose veins
Shortness of breath, asthma
Cancer
Neurological (e.g. MS, Parkinson's, chronic pain)
Epilepsy, seizures
Headaches, Migraines
Dizziness, ringing in the ears
Digestive conditions (e.g. Crohn's, IBS)
Gas, bloating, constipation
Kidney disease, infection
Arthritis (rheumatoid, osteoarthritis)
Osteoporosis, degenerative spine/disk
Scoliosis
Broken bones
Allergies
Diabetes
Endocrine/thyroid conditions
Depression, anxiety
Memory Loss, confusion, easily overwhelmed

Explain in detail, including treatment received:

Are any parts of your body on which the therapist should concentrate or do you have any other special request?
First Client's Signature*
Second Client's Name

First Name*

Middle Name

Last Name*
Second Client's Date of Birth*
Second Client's Health History
Have you ever received professional massage/bodywork before?*
No
Yes

How recently?
What kind of pressure do you prefer?*
Light
Medium
Firm
Combo
Do you currently have any condition?
Pregnancy
Cancer
Broken Bones
Hearth Condition
Surgeries
Other
None

List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):
Do these symptoms interfere with your activities of daily living (e.g., sleep, exercise, work, childcare)?*
No
Yes
N/A
Have you had any injuries or surgeries in the past that may influence today's treatment? Choose any of the following health conditions that you currently have. Please answer honestly, as massage may not be indicated for the following conditions.
Blood Cloths
Infections
Flu/Fever
Congestive Heart Failure
Contagious Diseases
Pitted Edema
None
Please indicate conditions that you have or have had in the past.
Muscle or joint pain
Muscle or joint stiffness
Numbness or tingling
Swelling
Bruise easily
Sensitive to touch/pressure
High/Low blood pressure
Stroke, heart attack
Varicose veins
Shortness of breath, asthma
Cancer
Neurological (e.g. MS, Parkinson's, chronic pain)
Epilepsy, seizures
Headaches, Migraines
Dizziness, ringing in the ears
Digestive conditions (e.g. Crohn's, IBS)
Gas, bloating, constipation
Kidney disease, infection
Arthritis (rheumatoid, osteoarthritis)
Osteoporosis, degenerative spine/disk
Scoliosis
Broken bones
Allergies
Diabetes
Endocrine/thyroid conditions
Depression, anxiety
Memory Loss, confusion, easily overwhelmed

Explain in detail, including treatment received:

Are any parts of your body on which the therapist should concentrate or do you have any other special request?
Third Client's Name

First Name*

Middle Name

Last Name*
Third Client's Date of Birth*
Third Client's Health History
Have you ever received professional massage/bodywork before?*
No
Yes

How recently?
What kind of pressure do you prefer?*
Light
Medium
Firm
Combo
Do you currently have any condition?
Pregnancy
Cancer
Broken Bones
Hearth Condition
Surgeries
Other
None

List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):
Do these symptoms interfere with your activities of daily living (e.g., sleep, exercise, work, childcare)?*
No
Yes
N/A
Have you had any injuries or surgeries in the past that may influence today's treatment? Choose any of the following health conditions that you currently have. Please answer honestly, as massage may not be indicated for the following conditions.
Blood Cloths
Infections
Flu/Fever
Congestive Heart Failure
Contagious Diseases
Pitted Edema
None
Please indicate conditions that you have or have had in the past.
Muscle or joint pain
Muscle or joint stiffness
Numbness or tingling
Swelling
Bruise easily
Sensitive to touch/pressure
High/Low blood pressure
Stroke, heart attack
Varicose veins
Shortness of breath, asthma
Cancer
Neurological (e.g. MS, Parkinson's, chronic pain)
Epilepsy, seizures
Headaches, Migraines
Dizziness, ringing in the ears
Digestive conditions (e.g. Crohn's, IBS)
Gas, bloating, constipation
Kidney disease, infection
Arthritis (rheumatoid, osteoarthritis)
Osteoporosis, degenerative spine/disk
Scoliosis
Broken bones
Allergies
Diabetes
Endocrine/thyroid conditions
Depression, anxiety
Memory Loss, confusion, easily overwhelmed

Explain in detail, including treatment received:

Are any parts of your body on which the therapist should concentrate or do you have any other special request?
Fourth Client's Name

First Name*

Middle Name

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Health History
Have you ever received professional massage/bodywork before?*
No
Yes

How recently?
What kind of pressure do you prefer?*
Light
Medium
Firm
Combo
Do you currently have any condition?
Pregnancy
Cancer
Broken Bones
Hearth Condition
Surgeries
Other
None

List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):
Do these symptoms interfere with your activities of daily living (e.g., sleep, exercise, work, childcare)?*
No
Yes
N/A
Have you had any injuries or surgeries in the past that may influence today's treatment? Choose any of the following health conditions that you currently have. Please answer honestly, as massage may not be indicated for the following conditions.
Blood Cloths
Infections
Flu/Fever
Congestive Heart Failure
Contagious Diseases
Pitted Edema
None
Please indicate conditions that you have or have had in the past.
Muscle or joint pain
Muscle or joint stiffness
Numbness or tingling
Swelling
Bruise easily
Sensitive to touch/pressure
High/Low blood pressure
Stroke, heart attack
Varicose veins
Shortness of breath, asthma
Cancer
Neurological (e.g. MS, Parkinson's, chronic pain)
Epilepsy, seizures
Headaches, Migraines
Dizziness, ringing in the ears
Digestive conditions (e.g. Crohn's, IBS)
Gas, bloating, constipation
Kidney disease, infection
Arthritis (rheumatoid, osteoarthritis)
Osteoporosis, degenerative spine/disk
Scoliosis
Broken bones
Allergies
Diabetes
Endocrine/thyroid conditions
Depression, anxiety
Memory Loss, confusion, easily overwhelmed

Explain in detail, including treatment received:

Are any parts of your body on which the therapist should concentrate or do you have any other special request?
Fifth Client's Name

First Name*

Middle Name

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Health History
Have you ever received professional massage/bodywork before?*
No
Yes

How recently?
What kind of pressure do you prefer?*
Light
Medium
Firm
Combo
Do you currently have any condition?
Pregnancy
Cancer
Broken Bones
Hearth Condition
Surgeries
Other
None

List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):
Do these symptoms interfere with your activities of daily living (e.g., sleep, exercise, work, childcare)?*
No
Yes
N/A
Have you had any injuries or surgeries in the past that may influence today's treatment? Choose any of the following health conditions that you currently have. Please answer honestly, as massage may not be indicated for the following conditions.
Blood Cloths
Infections
Flu/Fever
Congestive Heart Failure
Contagious Diseases
Pitted Edema
None
Please indicate conditions that you have or have had in the past.
Muscle or joint pain
Muscle or joint stiffness
Numbness or tingling
Swelling
Bruise easily
Sensitive to touch/pressure
High/Low blood pressure
Stroke, heart attack
Varicose veins
Shortness of breath, asthma
Cancer
Neurological (e.g. MS, Parkinson's, chronic pain)
Epilepsy, seizures
Headaches, Migraines
Dizziness, ringing in the ears
Digestive conditions (e.g. Crohn's, IBS)
Gas, bloating, constipation
Kidney disease, infection
Arthritis (rheumatoid, osteoarthritis)
Osteoporosis, degenerative spine/disk
Scoliosis
Broken bones
Allergies
Diabetes
Endocrine/thyroid conditions
Depression, anxiety
Memory Loss, confusion, easily overwhelmed

Explain in detail, including treatment received:

Are any parts of your body on which the therapist should concentrate or do you have any other special request?
Sixth Client's Name

First Name*

Middle Name

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Health History
Have you ever received professional massage/bodywork before?*
No
Yes

How recently?
What kind of pressure do you prefer?*
Light
Medium
Firm
Combo
Do you currently have any condition?
Pregnancy
Cancer
Broken Bones
Hearth Condition
Surgeries
Other
None

List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):
Do these symptoms interfere with your activities of daily living (e.g., sleep, exercise, work, childcare)?*
No
Yes
N/A
Have you had any injuries or surgeries in the past that may influence today's treatment? Choose any of the following health conditions that you currently have. Please answer honestly, as massage may not be indicated for the following conditions.
Blood Cloths
Infections
Flu/Fever
Congestive Heart Failure
Contagious Diseases
Pitted Edema
None
Please indicate conditions that you have or have had in the past.
Muscle or joint pain
Muscle or joint stiffness
Numbness or tingling
Swelling
Bruise easily
Sensitive to touch/pressure
High/Low blood pressure
Stroke, heart attack
Varicose veins
Shortness of breath, asthma
Cancer
Neurological (e.g. MS, Parkinson's, chronic pain)
Epilepsy, seizures
Headaches, Migraines
Dizziness, ringing in the ears
Digestive conditions (e.g. Crohn's, IBS)
Gas, bloating, constipation
Kidney disease, infection
Arthritis (rheumatoid, osteoarthritis)
Osteoporosis, degenerative spine/disk
Scoliosis
Broken bones
Allergies
Diabetes
Endocrine/thyroid conditions
Depression, anxiety
Memory Loss, confusion, easily overwhelmed

Explain in detail, including treatment received:

Are any parts of your body on which the therapist should concentrate or do you have any other special request?
Seventh Client's Name

First Name*

Middle Name

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Health History
Have you ever received professional massage/bodywork before?*
No
Yes

How recently?
What kind of pressure do you prefer?*
Light
Medium
Firm
Combo
Do you currently have any condition?
Pregnancy
Cancer
Broken Bones
Hearth Condition
Surgeries
Other
None

List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):
Do these symptoms interfere with your activities of daily living (e.g., sleep, exercise, work, childcare)?*
No
Yes
N/A
Have you had any injuries or surgeries in the past that may influence today's treatment? Choose any of the following health conditions that you currently have. Please answer honestly, as massage may not be indicated for the following conditions.
Blood Cloths
Infections
Flu/Fever
Congestive Heart Failure
Contagious Diseases
Pitted Edema
None
Please indicate conditions that you have or have had in the past.
Muscle or joint pain
Muscle or joint stiffness
Numbness or tingling
Swelling
Bruise easily
Sensitive to touch/pressure
High/Low blood pressure
Stroke, heart attack
Varicose veins
Shortness of breath, asthma
Cancer
Neurological (e.g. MS, Parkinson's, chronic pain)
Epilepsy, seizures
Headaches, Migraines
Dizziness, ringing in the ears
Digestive conditions (e.g. Crohn's, IBS)
Gas, bloating, constipation
Kidney disease, infection
Arthritis (rheumatoid, osteoarthritis)
Osteoporosis, degenerative spine/disk
Scoliosis
Broken bones
Allergies
Diabetes
Endocrine/thyroid conditions
Depression, anxiety
Memory Loss, confusion, easily overwhelmed

Explain in detail, including treatment received:

Are any parts of your body on which the therapist should concentrate or do you have any other special request?
Eighth Client's Name

First Name*

Middle Name

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Health History
Have you ever received professional massage/bodywork before?*
No
Yes

How recently?
What kind of pressure do you prefer?*
Light
Medium
Firm
Combo
Do you currently have any condition?
Pregnancy
Cancer
Broken Bones
Hearth Condition
Surgeries
Other
None

List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):
Do these symptoms interfere with your activities of daily living (e.g., sleep, exercise, work, childcare)?*
No
Yes
N/A
Have you had any injuries or surgeries in the past that may influence today's treatment? Choose any of the following health conditions that you currently have. Please answer honestly, as massage may not be indicated for the following conditions.
Blood Cloths
Infections
Flu/Fever
Congestive Heart Failure
Contagious Diseases
Pitted Edema
None
Please indicate conditions that you have or have had in the past.
Muscle or joint pain
Muscle or joint stiffness
Numbness or tingling
Swelling
Bruise easily
Sensitive to touch/pressure
High/Low blood pressure
Stroke, heart attack
Varicose veins
Shortness of breath, asthma
Cancer
Neurological (e.g. MS, Parkinson's, chronic pain)
Epilepsy, seizures
Headaches, Migraines
Dizziness, ringing in the ears
Digestive conditions (e.g. Crohn's, IBS)
Gas, bloating, constipation
Kidney disease, infection
Arthritis (rheumatoid, osteoarthritis)
Osteoporosis, degenerative spine/disk
Scoliosis
Broken bones
Allergies
Diabetes
Endocrine/thyroid conditions
Depression, anxiety
Memory Loss, confusion, easily overwhelmed

Explain in detail, including treatment received:

Are any parts of your body on which the therapist should concentrate or do you have any other special request?
Ninth Client's Name

First Name*

Middle Name

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Health History
Have you ever received professional massage/bodywork before?*
No
Yes

How recently?
What kind of pressure do you prefer?*
Light
Medium
Firm
Combo
Do you currently have any condition?
Pregnancy
Cancer
Broken Bones
Hearth Condition
Surgeries
Other
None

List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):
Do these symptoms interfere with your activities of daily living (e.g., sleep, exercise, work, childcare)?*
No
Yes
N/A
Have you had any injuries or surgeries in the past that may influence today's treatment? Choose any of the following health conditions that you currently have. Please answer honestly, as massage may not be indicated for the following conditions.
Blood Cloths
Infections
Flu/Fever
Congestive Heart Failure
Contagious Diseases
Pitted Edema
None
Please indicate conditions that you have or have had in the past.
Muscle or joint pain
Muscle or joint stiffness
Numbness or tingling
Swelling
Bruise easily
Sensitive to touch/pressure
High/Low blood pressure
Stroke, heart attack
Varicose veins
Shortness of breath, asthma
Cancer
Neurological (e.g. MS, Parkinson's, chronic pain)
Epilepsy, seizures
Headaches, Migraines
Dizziness, ringing in the ears
Digestive conditions (e.g. Crohn's, IBS)
Gas, bloating, constipation
Kidney disease, infection
Arthritis (rheumatoid, osteoarthritis)
Osteoporosis, degenerative spine/disk
Scoliosis
Broken bones
Allergies
Diabetes
Endocrine/thyroid conditions
Depression, anxiety
Memory Loss, confusion, easily overwhelmed

Explain in detail, including treatment received:

Are any parts of your body on which the therapist should concentrate or do you have any other special request?
Tenth Client's Name

First Name*

Middle Name

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Health History
Have you ever received professional massage/bodywork before?*
No
Yes

How recently?
What kind of pressure do you prefer?*
Light
Medium
Firm
Combo
Do you currently have any condition?
Pregnancy
Cancer
Broken Bones
Hearth Condition
Surgeries
Other
None

List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):
Do these symptoms interfere with your activities of daily living (e.g., sleep, exercise, work, childcare)?*
No
Yes
N/A
Have you had any injuries or surgeries in the past that may influence today's treatment? Choose any of the following health conditions that you currently have. Please answer honestly, as massage may not be indicated for the following conditions.
Blood Cloths
Infections
Flu/Fever
Congestive Heart Failure
Contagious Diseases
Pitted Edema
None
Please indicate conditions that you have or have had in the past.
Muscle or joint pain
Muscle or joint stiffness
Numbness or tingling
Swelling
Bruise easily
Sensitive to touch/pressure
High/Low blood pressure
Stroke, heart attack
Varicose veins
Shortness of breath, asthma
Cancer
Neurological (e.g. MS, Parkinson's, chronic pain)
Epilepsy, seizures
Headaches, Migraines
Dizziness, ringing in the ears
Digestive conditions (e.g. Crohn's, IBS)
Gas, bloating, constipation
Kidney disease, infection
Arthritis (rheumatoid, osteoarthritis)
Osteoporosis, degenerative spine/disk
Scoliosis
Broken bones
Allergies
Diabetes
Endocrine/thyroid conditions
Depression, anxiety
Memory Loss, confusion, easily overwhelmed

Explain in detail, including treatment received:

Are any parts of your body on which the therapist should concentrate or do you have any other special request?
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.
Disclaimer

The above information is accurate and true to the best of my knowledge. I understand that massage therapist do not diagnose disease, prescribe medication or manipulate bones. I further understand that massage therapy is not a substitute for medical attention or examination. Because massage therapy should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I take responsibility for alerting my practitioner to any physical, mental or emotional changes that occur with my health and understand that shall be no liability on the practitioner's part should I forgot to do so. 

It is also understood that any illicit or sexual suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of scheduled appointment. 

I, also, understand that cancelled or missed appointments without 24hours notice (medical emergencies excluded)may be charged in full to my credit card on file for the price of missed session.

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 Health History
Have you ever received professional massage/bodywork before?*
No
Yes

How recently?
What kind of pressure do you prefer?*
Light
Medium
Firm
Combo
Do you currently have any condition?
Pregnancy
Cancer
Broken Bones
Hearth Condition
Surgeries
Other
None

List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):
Do these symptoms interfere with your activities of daily living (e.g., sleep, exercise, work, childcare)?*
No
Yes
N/A
Have you had any injuries or surgeries in the past that may influence today's treatment? Choose any of the following health conditions that you currently have. Please answer honestly, as massage may not be indicated for the following conditions.
Blood Cloths
Infections
Flu/Fever
Congestive Heart Failure
Contagious Diseases
Pitted Edema
None
Please indicate conditions that you have or have had in the past.
Muscle or joint pain
Muscle or joint stiffness
Numbness or tingling
Swelling
Bruise easily
Sensitive to touch/pressure
High/Low blood pressure
Stroke, heart attack
Varicose veins
Shortness of breath, asthma
Cancer
Neurological (e.g. MS, Parkinson's, chronic pain)
Epilepsy, seizures
Headaches, Migraines
Dizziness, ringing in the ears
Digestive conditions (e.g. Crohn's, IBS)
Gas, bloating, constipation
Kidney disease, infection
Arthritis (rheumatoid, osteoarthritis)
Osteoporosis, degenerative spine/disk
Scoliosis
Broken bones
Allergies
Diabetes
Endocrine/thyroid conditions
Depression, anxiety
Memory Loss, confusion, easily overwhelmed

Explain in detail, including treatment received:

Are any parts of your body on which the therapist should concentrate or do you have any other special request?
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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