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In Washington State, licensed massage therapists are healthcare professionals. For safety and security purposes, this online intake needs to get completed before receiving treatment. All fields require an answer or it will not submit. Thank you!





INFORMED CONSENT & POLICIES

BY SIGNING BELOW, YOU ACKNOWLEDGE AND AGREE TO THE FOLLOWING:

Therapeutic massage is not a substitute for traditional medical treatment or medications. The massage therapist does not diagnose illnesses and injuries or prescribe medications. You are at least 18 years of age. You have clearance from your physician to receive massage therapy. You give your permission to receive it. You will inform your massage therapist of all medical conditions, allergies, and medications and if there are any changes. You understand there may be additional risks based on your physical condition. The risks associated with massage therapy, such as cupping, hot stones, deep tissue, Gua sha, and Ashiatsu, include but are not limited to superficial bruising, short-term muscle soreness, burns, and exacerbation of undiscovered injury. Because massage therapy involves constant touch and close physical proximity over an extended period, you understand there may be an elevated risk of disease transmission, including COVID-19.

You will inform the massage therapist of any discomfort you may feel during the massage session so they may adjust accordingly. At any time, you or the massage therapist may terminate the session. You will not hold the therapist responsible for any pain or discomfort you experience during or after the session. There is no genital or perineal massage (massaging the tissues between the anus and genitals). Any illicit or sexual innuendos or advances will result in the termination of the session. And you will be liable for full payment of the session. The massage therapist does not date clients to maintain professional boundaries set by the law. 

All communication between you and the massage therapist, such as conversations during sessions, phone calls, texts, letters, and e-mails, is confidential under the constraints of the law. It also applies to any session documentation and intake forms. These get deleted or safely secured in a locked closet and password-protected devices/accounts. You permit the massage therapist to contact your emergency contact(s) in case of an emergency.


PERSONAL BELONGINGS POLICY:

Vita Nova Massage PLLC is not responsible for lost, stolen, or damaged personal belongings. Wearing clothes and jewelry or placing items on or near the massage table during the session may get damaged by techniques, lotions, and oils. Phones, watches, and other electronics must be silent and stored away from the massage table. 


CANCELLATION & PAYMENT POLICIES:

No-shows or cancellations within 48 hours of the scheduled appointment get charged the entire original service amount. And this includes rescheduling or wanting to shorten your session. Being over 30 minutes late or inappropriate is an automatically charged cancellation fee. If you arrive late, it is at the massage therapist's discretion whether you receive your full-time. A 50% deposit is due for the first session upon booking. Your credit card on file gets charged for this and future transactions. Payment is due at the end of every session. If it's been over six months since your last visit, a new credit card on file and a 50% deposit are due for that next session. Vita Nova Massage PLLC does not offer refunds.


GIFT CERTIFICATE POLICIES: 

Gift certificates get sold in dollar amounts. They are not exchangeable for cash. In Washington State, gift certificates do not expire unless donated to a raffle, auction, and other events. If Vita Nova Massage's rates increase before a gift certificate is redeemed, the recipient may have a remaining balance to pay with another form of payment. Gift certificate recipients must reserve their appointment with a credit card on file per the cancellation policy. Gift certificates are forfeited if the recipient does not cancel within 48 hours. Or the credit card on file gets charged. The massage therapist must verify the authenticity of the physical gift certificate or e-gift card. If not, another form of payment is needed. A receipt or picture of the certificate does not qualify. Vita Nova Massage PLLC is not responsible for lost or stolen gift certificates. 

 

By signing this form, you waive and release Vita Nova Massage PLLC and Antonietta Ramirez, Owner, and licensed massage therapist, from any liability, past, present, and future relating to massage therapy and bodywork.





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

First Name*

Last Name*

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

OCCUPATION: *

HOBBIES: *

Do you have any difficulty lying on your front, back, or side? If yes, please explain: *

Do you sit for long hours or perform repetitive movements (work, sports, etc.)? If yes, please describe: *

Do you experience stress in your work, family, or others aspects of your life? If yes, do you think it affects any of the following: muscle tension, anxiety, insomnia, irritability, or other? *

Are there any areas of the body where you are experiencing tension, stiffness, pain, or other discomforts now? If yes, please identify: *

Do you have any specific goals in mind for this massage session? *

In general, do you run hot or cold? I have plenty of blankets, two heaters, an a/c unit, a fan, and a table warmer. I can adjust them throughout the session to your comfort.

Generally, I check in 1-2 times during the massage to help establish trust and ensure your comfort. If at any time you look uncomfortable, I will check in again. Because I use a lot of movement and intimate massage styles, some clients may need frequent communication to feel safe and relaxed. How much communication would you like during the session?

List any allergies/sensitivities here (think more massage-related, like incense, peppermint, vanilla, olive oil, mango butter, and grapeseed oil). I clean with Prevention, an EPA-approved hydrogen peroxide disinfectant. I use Persil laundry detergent for washing my linens. *Substitutions may not be available if this section gets completed with less than 8 hours' notice. *
Please check any condition below that applies to you:
Fibromyalgia
TMJ
carpal tunnel syndrome
contagious skin condition
current fever or swollen glands
deep vein thrombosis/ blood clots
easy bruising
headaches/migraines
heart or circulatory condition
high or low blood pressure
open sores or wounds
pregnancy
recent injury or surgery
varicose veins or phlebitis
any issues with touch/massage
currently being treated for depression
depression, blues, mood issues in past
joint disorder/arthritis/osteoporosis

Are you currently under medical supervision (including chiropractic) or taking any medications that we should be aware of? If yes, please explain/list:

Please explain any condition that you have marked above and anything else about your health history that you think would be useful for your massage therapist to know to plan a safe and effective massage session for you:

Can you please tell us how you learned of Vita Nova Massage? (Thank you!):
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 practice updates by e-mail. I do not spam or sell emails. You can always unsubscribe at any time. This box is pre-selected not out of deceit but for convenience. Previously, clients who wanted to be email subscribers didn't see this option when it was left unmarked.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Communication Preferences
Does your healthcare provider have permission to contact you regarding your health information and appointments via (required to select at least one): *
Email
Phone Calls
Voicemails
Text messaging
FRIENDLY NOTICE:

Thank you for completing the first half of this intake. We will discuss your draping and massage preferences and any areas to avoid in person. Please arrive a little early for that. During the session, you may drool, snore, and pass gas. These normal bodily functions can get activated when the nervous system is relaxed. It is nothing to be embarrassed about. Also, good hygiene is appreciated, but a little sweat or minimal body odor does not bother me. Please don't apologize for not shaving. Having body hair is normal. 




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.

 To ensure a minor did not sign this document, an additional release will need to be signed in person by the parent or guardian at the first session. This must be completed before a minor can receive treatment. If not, the appointment will be considered a no-show. The cancellation fee will be charged. 




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*

Relationship*

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

OCCUPATION: *

HOBBIES: *

Do you have any difficulty lying on your front, back, or side? If yes, please explain: *

Do you sit for long hours or perform repetitive movements (work, sports, etc.)? If yes, please describe: *

Do you experience stress in your work, family, or others aspects of your life? If yes, do you think it affects any of the following: muscle tension, anxiety, insomnia, irritability, or other? *

Are there any areas of the body where you are experiencing tension, stiffness, pain, or other discomforts now? If yes, please identify: *

Do you have any specific goals in mind for this massage session? *

In general, do you run hot or cold? I have plenty of blankets, two heaters, an a/c unit, a fan, and a table warmer. I can adjust them throughout the session to your comfort.

Generally, I check in 1-2 times during the massage to help establish trust and ensure your comfort. If at any time you look uncomfortable, I will check in again. Because I use a lot of movement and intimate massage styles, some clients may need frequent communication to feel safe and relaxed. How much communication would you like during the session?

List any allergies/sensitivities here (think more massage-related, like incense, peppermint, vanilla, olive oil, mango butter, and grapeseed oil). I clean with Prevention, an EPA-approved hydrogen peroxide disinfectant. I use Persil laundry detergent for washing my linens. *Substitutions may not be available if this section gets completed with less than 8 hours' notice. *
Please check any condition below that applies to you:
Fibromyalgia
TMJ
carpal tunnel syndrome
contagious skin condition
current fever or swollen glands
deep vein thrombosis/ blood clots
easy bruising
headaches/migraines
heart or circulatory condition
high or low blood pressure
open sores or wounds
pregnancy
recent injury or surgery
varicose veins or phlebitis
any issues with touch/massage
currently being treated for depression
depression, blues, mood issues in past
joint disorder/arthritis/osteoporosis

Are you currently under medical supervision (including chiropractic) or taking any medications that we should be aware of? If yes, please explain/list:

Please explain any condition that you have marked above and anything else about your health history that you think would be useful for your massage therapist to know to plan a safe and effective massage session for you:

Can you please tell us how you learned of Vita Nova Massage? (Thank you!):
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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