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New Client Intake Form

Welcome, and thank you for choosing The Care Collective!

POLICY – PLEASE READ

  • If cancellation or changes are necessary, please give 24-hour notice. If you do not give notice you will be charged for the full price of the appointment missed. 
  • Sessions begin and end at scheduled times. If you arrive late, you will lose that time off your session and will still be charged full price.
  • Please do not be under the influence of alcohol or drugs because massage can be dangerous to you under these conditions.
  • Clients must provide a health history and update when necessary.
  • Wear loose or comfortable clothing on the day of your session.
  • Payment is expected at the time service is rendered.
  • Sexual harassment is not tolerated.
  • If the practitioner’s safety feels compromised, the session is stopped immediately.


Massage Therapy Informed Consent

I (client) understand that massage therapy provided by, The Care Collective is intended to enhance relaxation, reduce pain caused by muscle tension, increase range of motion, improve circulation and offer a positive experience of touch. The general benefits of massage, possible massage contraindications and the treatment procedure have been explained to me. I understand that massage therapy is not a substitute for medical treatment or medications, and that it is recommended that I concurrently work with my Primary Caregiver for any condition I may have. I am aware that the massage therapist does not diagnose illness or disease, does not prescribe medications, and that spinal manipulations are not part of massage therapy. I have informed the massage therapist of all my known physical conditions, medical conditions and medications, and I will keep the massage therapist updated on any changes. I understand that there shall be no liability on the practitioner’s part due to my forgetting to relay any pertinent information. If I experience any pain or discomfort during the session, I immediately communicate that to the therapist so the treatment can be adjusted. I have reviewed the therapist’s policies, and I understand them and agree to abide by them. I acknowledge that with any treatment there can be risks and I assume those risks.

Today's Date: June 24, 2025 

Please select who will be participating...
AdultMinor
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First Participant's Name
First Name*
Middle Name
Last Name*
First Participant's Date of Birth*
Date of Birth
First Participant's Information

Medical History and Information 

Check any or all that apply to your present health:
headaches
chronic pain
varicose veins
vision problems
muscle or joint pain
sinus problems
numbness/tingling
jaw pain/teeth grinding
sprains/strains
diabetes
fatigue
scoliosis
endometriosis
painful periods
depression
arthritis
sleep difficulties
tendonitis
skin problems
allergies
high/low blood pressure
hypermobility
osteoporosis or osteopenia
pregnant

If pregnant, how many weeks? (please ensure that you are booked with a "prenatal massage appointment")
infectious disease/active infection

If yes, date of last treatment.
blood clots or blood clotting disorders

If yes, date of last treatment.
cancer/tumors

If yes, diagnosis and date of last treatment.
implants such as breast, calves, gluteal OR medical implants such as pacemaker or central venous catheter.

If you have implants, please list.
joint replacements such as hip, shoulder, knee etc

If you have had any joint replacements please list.

Please list all surgeries with dates.

List all medications/herbs/vitamins and dosage.

What other treatments are you receiving and by whom (acupuncture, physical therapy, chiropractic, naturopathic):

Do you have any allergies that we should consider? Example: coconut oil, nuts, fragrances, essential oils, wheat germ, etc.?
Do you give consent for gluteal massage? (Buttock region)*
Yes
No
Are you comfortable with the potential for temporary skin marks associated with cupping therapy?*
Yes
No

Occupation

Is there any other information that you would like for your massage therapist to know?
First Participant's Signature*
Parent or Guardian's Email Address
Email
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
Please let us know how you found us:

Please let us know how you found us:

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. If the minor is 15 or under, a parent or guardian needs to stay in the room during the massage.



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*
Middle Name
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Information

Medical History and Information 

Check any or all that apply to your present health:
headaches
chronic pain
varicose veins
vision problems
muscle or joint pain
sinus problems
numbness/tingling
jaw pain/teeth grinding
sprains/strains
diabetes
fatigue
scoliosis
endometriosis
painful periods
depression
arthritis
sleep difficulties
tendonitis
skin problems
allergies
high/low blood pressure
hypermobility
osteoporosis or osteopenia
pregnant

If pregnant, how many weeks? (please ensure that you are booked with a "prenatal massage appointment")
infectious disease/active infection

If yes, date of last treatment.
blood clots or blood clotting disorders

If yes, date of last treatment.
cancer/tumors

If yes, diagnosis and date of last treatment.
implants such as breast, calves, gluteal OR medical implants such as pacemaker or central venous catheter.

If you have implants, please list.
joint replacements such as hip, shoulder, knee etc

If you have had any joint replacements please list.

Please list all surgeries with dates.

List all medications/herbs/vitamins and dosage.

What other treatments are you receiving and by whom (acupuncture, physical therapy, chiropractic, naturopathic):

Do you have any allergies that we should consider? Example: coconut oil, nuts, fragrances, essential oils, wheat germ, etc.?
Do you give consent for gluteal massage? (Buttock region)*
Yes
No
Are you comfortable with the potential for temporary skin marks associated with cupping therapy?*
Yes
No

Occupation

Is there any other information that you would like for your massage therapist to know?
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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