Loading...

In Washington State, licensed massage therapists are healthcare professionals. For safety and security purposes, this online intake needs to be completed before receiving treatment. 




 

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 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, Ashiatsu, hot stones, deep tissue, Gua Sha, and others include, but are not limited to, superficial bruising, short-term muscle soreness, burns, and exacerbation of undiscovered injury. You understand that, because massage therapy work involves maintained touch and close physical proximity over an extended period, there may be an elevated risk of disease transmission, including COVID-19.

It is your responsibility to 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.

Throughout the service, the massage therapist will always use a drape, meaning a blanket and sheet, for your security and modesty. There is no genital massage or perineal massage (massaging the tissues between the anus and genitals). Any illicit or sexual innuendos or advances will result in termination of the session and you will be liable for full payment of the session. To maintain professional boundaries set by the law, the massage therapist does not date clients.

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.

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.

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.

If you’re late, it is at the massage therapist's discretion whether you receive your full time. 

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

 

COVID-19 OFFICE PROTOCOLS

BY SIGNING BELOW, YOU AGREE TO FOLLOW THESE PROTOCOLS:

  1. Temperatures will be checked with a contact-less thermometer to screen for Covid-19. Any high temperatures or other Covid-19 symptoms being displayed will require the session to be rescheduled. 
  2. Hands will need to be washed or sanitized before entering the massage studio. 
  3. Masks are required for safety and liability purposes. No mask, no service, no exceptions. 
  4. No guests are allowed in the waiting areas or massage studio. Appointments will be staggered by 30-60 minute blocks. This is to ensure your massage therapist has adequate time to air out the room and to thoroughly complete cleaning/sanitizing protocols set by the CDC, OSHA, and DOH. 

 










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

First Name*

Last Name*

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

Please list any previous or existing health conditions (pregnancy, cancer, Ehlers-Danlos Syndrome, vertigo, arthritis, osteoporosis, etc.) surgeries, injuries, and current medication. Serious conditions such as recent blood clots or stroke, UNCONTROLLED hypertension, UNCONTROLLED diabetes, and UNCONTROLLED preeclampsia will require a doctor’s note as they can be worsened by massage. *

Describe your goals/focus areas and list any favorite modalities or techniques. *

Pressure Preference: Do you have a low or high pain tolerance? Overall, do you like light, medium, or firm/deep pressure? Or do you prefer light pressure on your legs and firmer pressure on your back, etc? It’s okay if you’re unsure right now. We can always make adjustments throughout the massage. *

Please list any allergies/sensitivities: (Such as essential oils, incense, avocado oil, mango oil, grape seed oil, cocoa butter, sunflower oil, arnica oil, sage, etc.) If this intake was completed less than 24 hours before the appointment and you’re allergic to all of the above, then I may not be able to find a substitute hypoallergenic cream or oil in time. And incense may have been burned. Our building is not scent-free, but it is generally not overwhelming to smell. *

Please list any areas to avoid: (Such as the face, scalp, feet) *
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?
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?
I am not trained to perform breast work, but you have the option to leave your breasts uncovered. This question applies to all genders and identities. *
No preference
keep breasts covered throughout the massage
keep breasts uncovered throughout the massage
keep breasts covered during chest work
keep breasts uncovered during chest work
keep breasts covered during abdominal work
keep breasts uncovered during abdominal work
Do you want your massage therapist to wear gloves during the session?*
No preference
No
Yes
In ADDITION to a mask, do you want your massage therapist to wear a face shield during neck, scalp, and facial massage? *
No preference
No
Yes
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 and news by e-mail. I do not spam or sell emails. I publish very little newsletters. I’m too busy massaging all of you! :)
Emergency Contact

Emergency Contact's 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

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. 


Parent or Guardian's Name

First Name*

Last Name*

Relationship*

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

Please list any previous or existing health conditions (pregnancy, cancer, Ehlers-Danlos Syndrome, vertigo, arthritis, osteoporosis, etc.) surgeries, injuries, and current medication. Serious conditions such as recent blood clots or stroke, UNCONTROLLED hypertension, UNCONTROLLED diabetes, and UNCONTROLLED preeclampsia will require a doctor’s note as they can be worsened by massage. *

Describe your goals/focus areas and list any favorite modalities or techniques. *

Pressure Preference: Do you have a low or high pain tolerance? Overall, do you like light, medium, or firm/deep pressure? Or do you prefer light pressure on your legs and firmer pressure on your back, etc? It’s okay if you’re unsure right now. We can always make adjustments throughout the massage. *

Please list any allergies/sensitivities: (Such as essential oils, incense, avocado oil, mango oil, grape seed oil, cocoa butter, sunflower oil, arnica oil, sage, etc.) If this intake was completed less than 24 hours before the appointment and you’re allergic to all of the above, then I may not be able to find a substitute hypoallergenic cream or oil in time. And incense may have been burned. Our building is not scent-free, but it is generally not overwhelming to smell. *

Please list any areas to avoid: (Such as the face, scalp, feet) *
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?
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?
I am not trained to perform breast work, but you have the option to leave your breasts uncovered. This question applies to all genders and identities. *
No preference
keep breasts covered throughout the massage
keep breasts uncovered throughout the massage
keep breasts covered during chest work
keep breasts uncovered during chest work
keep breasts covered during abdominal work
keep breasts uncovered during abdominal work
Do you want your massage therapist to wear gloves during the session?*
No preference
No
Yes
In ADDITION to a mask, do you want your massage therapist to wear a face shield during neck, scalp, and facial massage? *
No preference
No
Yes
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!