Loading...

New Client Intake Form

Welcome, and thank you for choosing The Care Collective!

POLICY – PLEASE READ

  • If cancellation is 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.
  • 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.
  • Wear loose or comfortable clothes

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: April 25, 2024 

First Participant's Name

First Name*

Last Name*
First Participant's 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 problem
muscle or joint pain
blood clots
sinus problems
numbness/tingling
high/low blood pressure
jaw pain/teeth grinding
sprains/strains
diabetes
fatigue
scoliosis
cancer/tumors
depression
arthritis
infectious disease
sleep difficulties
tendonitis
skin problems
allergies
Women only:
pregnant
painful menstruation
endometriosis

If pregnant, what stage?

Other not listed:

List all medications/herbs/vitamins and dosage

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

If Yes, what is your doctors/practitioners phone number?
We typically use organic coconut oil, do you have an allergy to coconut oil?*
No
Yes
Are you opposed to gluteal massage?*
No
Yes

Occupation

What are you looking for in your massage today/is there anything specific you would like worked on?
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Medical History and Information 

Check any or all that apply to your present health:
headaches
chronic pain
varicose veins
vision problem
muscle or joint pain
blood clots
sinus problems
numbness/tingling
high/low blood pressure
jaw pain/teeth grinding
sprains/strains
diabetes
fatigue
scoliosis
cancer/tumors
depression
arthritis
infectious disease
sleep difficulties
tendonitis
skin problems
allergies
Women only:
pregnant
painful menstruation
endometriosis

If pregnant, what stage?

Other not listed:

List all medications/herbs/vitamins and dosage

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

If Yes, what is your doctors/practitioners phone number?
We typically use organic coconut oil, do you have an allergy to coconut oil?*
No
Yes
Are you opposed to gluteal massage?*
No
Yes

Occupation

What are you looking for in your massage today/is there anything specific you would like worked on?
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Medical History and Information 

Check any or all that apply to your present health:
headaches
chronic pain
varicose veins
vision problem
muscle or joint pain
blood clots
sinus problems
numbness/tingling
high/low blood pressure
jaw pain/teeth grinding
sprains/strains
diabetes
fatigue
scoliosis
cancer/tumors
depression
arthritis
infectious disease
sleep difficulties
tendonitis
skin problems
allergies
Women only:
pregnant
painful menstruation
endometriosis

If pregnant, what stage?

Other not listed:

List all medications/herbs/vitamins and dosage

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

If Yes, what is your doctors/practitioners phone number?
We typically use organic coconut oil, do you have an allergy to coconut oil?*
No
Yes
Are you opposed to gluteal massage?*
No
Yes

Occupation

What are you looking for in your massage today/is there anything specific you would like worked on?
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Medical History and Information 

Check any or all that apply to your present health:
headaches
chronic pain
varicose veins
vision problem
muscle or joint pain
blood clots
sinus problems
numbness/tingling
high/low blood pressure
jaw pain/teeth grinding
sprains/strains
diabetes
fatigue
scoliosis
cancer/tumors
depression
arthritis
infectious disease
sleep difficulties
tendonitis
skin problems
allergies
Women only:
pregnant
painful menstruation
endometriosis

If pregnant, what stage?

Other not listed:

List all medications/herbs/vitamins and dosage

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

If Yes, what is your doctors/practitioners phone number?
We typically use organic coconut oil, do you have an allergy to coconut oil?*
No
Yes
Are you opposed to gluteal massage?*
No
Yes

Occupation

What are you looking for in your massage today/is there anything specific you would like worked on?
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Medical History and Information 

Check any or all that apply to your present health:
headaches
chronic pain
varicose veins
vision problem
muscle or joint pain
blood clots
sinus problems
numbness/tingling
high/low blood pressure
jaw pain/teeth grinding
sprains/strains
diabetes
fatigue
scoliosis
cancer/tumors
depression
arthritis
infectious disease
sleep difficulties
tendonitis
skin problems
allergies
Women only:
pregnant
painful menstruation
endometriosis

If pregnant, what stage?

Other not listed:

List all medications/herbs/vitamins and dosage

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

If Yes, what is your doctors/practitioners phone number?
We typically use organic coconut oil, do you have an allergy to coconut oil?*
No
Yes
Are you opposed to gluteal massage?*
No
Yes

Occupation

What are you looking for in your massage today/is there anything specific you would like worked on?
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Medical History and Information 

Check any or all that apply to your present health:
headaches
chronic pain
varicose veins
vision problem
muscle or joint pain
blood clots
sinus problems
numbness/tingling
high/low blood pressure
jaw pain/teeth grinding
sprains/strains
diabetes
fatigue
scoliosis
cancer/tumors
depression
arthritis
infectious disease
sleep difficulties
tendonitis
skin problems
allergies
Women only:
pregnant
painful menstruation
endometriosis

If pregnant, what stage?

Other not listed:

List all medications/herbs/vitamins and dosage

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

If Yes, what is your doctors/practitioners phone number?
We typically use organic coconut oil, do you have an allergy to coconut oil?*
No
Yes
Are you opposed to gluteal massage?*
No
Yes

Occupation

What are you looking for in your massage today/is there anything specific you would like worked on?
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Medical History and Information 

Check any or all that apply to your present health:
headaches
chronic pain
varicose veins
vision problem
muscle or joint pain
blood clots
sinus problems
numbness/tingling
high/low blood pressure
jaw pain/teeth grinding
sprains/strains
diabetes
fatigue
scoliosis
cancer/tumors
depression
arthritis
infectious disease
sleep difficulties
tendonitis
skin problems
allergies
Women only:
pregnant
painful menstruation
endometriosis

If pregnant, what stage?

Other not listed:

List all medications/herbs/vitamins and dosage

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

If Yes, what is your doctors/practitioners phone number?
We typically use organic coconut oil, do you have an allergy to coconut oil?*
No
Yes
Are you opposed to gluteal massage?*
No
Yes

Occupation

What are you looking for in your massage today/is there anything specific you would like worked on?
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Medical History and Information 

Check any or all that apply to your present health:
headaches
chronic pain
varicose veins
vision problem
muscle or joint pain
blood clots
sinus problems
numbness/tingling
high/low blood pressure
jaw pain/teeth grinding
sprains/strains
diabetes
fatigue
scoliosis
cancer/tumors
depression
arthritis
infectious disease
sleep difficulties
tendonitis
skin problems
allergies
Women only:
pregnant
painful menstruation
endometriosis

If pregnant, what stage?

Other not listed:

List all medications/herbs/vitamins and dosage

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

If Yes, what is your doctors/practitioners phone number?
We typically use organic coconut oil, do you have an allergy to coconut oil?*
No
Yes
Are you opposed to gluteal massage?*
No
Yes

Occupation

What are you looking for in your massage today/is there anything specific you would like worked on?
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Medical History and Information 

Check any or all that apply to your present health:
headaches
chronic pain
varicose veins
vision problem
muscle or joint pain
blood clots
sinus problems
numbness/tingling
high/low blood pressure
jaw pain/teeth grinding
sprains/strains
diabetes
fatigue
scoliosis
cancer/tumors
depression
arthritis
infectious disease
sleep difficulties
tendonitis
skin problems
allergies
Women only:
pregnant
painful menstruation
endometriosis

If pregnant, what stage?

Other not listed:

List all medications/herbs/vitamins and dosage

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

If Yes, what is your doctors/practitioners phone number?
We typically use organic coconut oil, do you have an allergy to coconut oil?*
No
Yes
Are you opposed to gluteal massage?*
No
Yes

Occupation

What are you looking for in your massage today/is there anything specific you would like worked on?
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Medical History and Information 

Check any or all that apply to your present health:
headaches
chronic pain
varicose veins
vision problem
muscle or joint pain
blood clots
sinus problems
numbness/tingling
high/low blood pressure
jaw pain/teeth grinding
sprains/strains
diabetes
fatigue
scoliosis
cancer/tumors
depression
arthritis
infectious disease
sleep difficulties
tendonitis
skin problems
allergies
Women only:
pregnant
painful menstruation
endometriosis

If pregnant, what stage?

Other not listed:

List all medications/herbs/vitamins and dosage

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

If Yes, what is your doctors/practitioners phone number?
We typically use organic coconut oil, do you have an allergy to coconut oil?*
No
Yes
Are you opposed to gluteal massage?*
No
Yes

Occupation

What are you looking for in your massage today/is there anything specific you would like worked on?
Participant's 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
Check to receive information, news, and discounts by e-mail.
A signed copy of this waiver will be sent to the email address you provide.
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 either stay in the room during the massage or on The Care Collective premises.


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*
Parent or Guardian's 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 problem
muscle or joint pain
blood clots
sinus problems
numbness/tingling
high/low blood pressure
jaw pain/teeth grinding
sprains/strains
diabetes
fatigue
scoliosis
cancer/tumors
depression
arthritis
infectious disease
sleep difficulties
tendonitis
skin problems
allergies
Women only:
pregnant
painful menstruation
endometriosis

If pregnant, what stage?

Other not listed:

List all medications/herbs/vitamins and dosage

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

If Yes, what is your doctors/practitioners phone number?
We typically use organic coconut oil, do you have an allergy to coconut oil?*
No
Yes
Are you opposed to gluteal massage?*
No
Yes

Occupation

What are you looking for in your massage today/is there anything specific you would like worked on?
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!