Therapeutic Massage Intake Form

*First Name
*Last Name
*Phone Number
*Email
*Preferred Contact
*Birthday
*Address Street 1
*Address Street 2
*Address City
*Address State
*Address Postal Code
*Occupation
*Have you had a professional massage before?
*If yes, how often do you receive massage therapy?
*Do you have any difficulty lying on your front, back, or side?
*Do you have any allergies to oils, lotions, or ointments?
*Are you wearing any hearing aids?
*Any particular area of the body where you're experiencing tension, stiffness, pain or discomfort?
*Do you have any particular goals in mind for this massage session?	required
*Would you like glute work done during your massage?
*Are you currently under medical supervision?
*If yes, how often?
*Are you currently taking any medication?
*If yes, please list or provide a list of medications to keep on file if it is extensive.
*Please check any condition listed below that applies to you
*If you marked cancer, please explain: Type of cancer
*Date diagnosed
*Are you currently being treated?
*When was your last treatment?
Are you under the care of an oncologist?*
*Name of oncologist if so
If you are pregnant, how far along are you? *
If you recently had a child, how long ago did you deliver/have a cesarean? **
Have you recently had any surgical procedures?*
*If yes, please list procedure and date
Are you currently still seeing a medical professional for the aforementioned procedure? ***
*Please explain anywhere yes was chosen (please number answers to match the question number)
*Is there anything else in your health history for your massage practitioner to know?
*Signature of Client

Cancellation/No Show Policy

In order to provide the best service to all our clients, we kindly request that you let us know up at least 24 hours in advance if you need to cancel or reschedule an appointment before the scheduled service time. If such changes are not made, a fee equivalent to 50% of the service cost will be applied. The same fee will be incurred if you are 15 minutes or more late for the scheduled start time you will have to reschedule to another day and pay the no show fee.

Any cancellation or reschedule made less than 24 hours in advance will result in a cancellation fee. The amount of the fee will be equal to $25 per service canceled.

**If you have had a cancer diagnosis within the past year, you are required to have clearance from your oncologist and will receive an oncology massage. Deep Tissue, and other general massage techniques are not permitted, and you must be worked on by a massage therapist with certification in oncology massage. We will not work on you without written consent and express permission by your oncologist first, their say supersedes the LMT’s.

**If you are pregnant, you must be at least 13 weeks pregnant, and you must have a doctors release to be worked on by any LMT, no exceptions. Your safety, and your child’s safety is very important to us.

*** If you have recently had a surgical procedure (generally 6weeks or less), you must have a doctor’s note to receive massage, no exceptions.

Therapeutic Massage Intake Form

AGE DISCLAIMER

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