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New Client Forms
The following client information, health background, liability waiver and policy notification are required prior to first service.
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Step
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Name
*
First
Last
Phone
*
Email
*
Date of birth
*
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Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Emergency Contact Name
*
First
Last
Emergency Contact Phone
Emergency Contact Email
Check here if client is under 18 and emergency contact is parent/guardian
Client is under 18
Form must be signed by parent/guardian
Next
Health questionaire
Do you have any specific pain or limitation?
*
Yes
No
(Current or chronic pain)
Please describe pain or limitation
Have you had any recent injuries or surgeries? (last 6-8 weeks)
*
Yes
No
Please describe injury or surgery
Have you dislocated a joint, have artificial joints/surgical hardware, or surgeries older than 3 months?
*
Yes
No
We don't want to traction a previously dislocated or artificial joint.
Please list joints and date of occurence
Just a rough date, month/year is fine. Year if more than 6 years.
Do you have any allergies?
*
Yes
No
We are mostly looking for oil or nut allergies that may be in lotions we use.
Please list allergies
Are you taking any medication
*
Yes
No
We are mostly looking for pain medication, blood pressure/thinner medication, or other that would affect the session.
Please list medications
Are there any other conditions or considerations we should know about?
*
Yes
No
Please list conditions or considerations
Signature (Parent/Guardian if client under 18)
*
Clear Signature
Previous
Next
Liability Waiver
I give my permission to receive stretching, massage, soft-tissue manipulations including, but not limited to, the use of tools, powered or otherwise, cups, hot and cold therapies.
*
I agree
I understand that therapeutic massage, stretching and bodywork is not a substitute for traditional medical treatment or medications.
*
I agree
I understand that the massage therapist does not diagnose illnesses or injuries, or prescribe medications.
*
I agree
I have clearance from my physician to receive stretching, bodywork, and massage therapy.
*
I agree
I understand the risks associated with massage therapy, stretching, and body work.I therefore release the company and the individual therapist from all liability concerning these injuries that may occur during the massage session.
*
I agree
Risks associated with massage therapy include, but are not limited to: • Superficial bruising • Short-term muscle soreness • Exacerbation of undiscovered injury I therefore release the company and the individual therapist from all liability concerning these injuries that may occur during the massage session.
I understand the importance of informing my therapist of all medical conditions and medications I am taking, and to let the therapist know about any changes to these. I understand that there may be additional risks based on my physical condition.
*
I agree
I understand that it is my responsibility to inform my therapist of any discomfort I may feel during the massage session so he/she may adjust accordingly.
*
I agree
I understand that I or the therapist may terminate the session at any time.
*
I agree
I have been given a chance to ask questions about the session and my questions have been answered.
*
I agree
Signature (Parent or guardian, if under 18)
*
Clear Signature
Previous
Next
Policy Notification
Late Arrival Policy
*
I agree
For scheduled appointments, we request that you arrive 5-10 minutes prior to your appointment time to allow time to fill out any required paperwork as well as answer any intake questions your therapist may have. We understand that issues can arise that may cause you to be late for your appointment. However, we ask that you call to inform us if this ever occurs so we can do our best to accommodate you. Appointment times are reserved for each client, so oftentimes we cannot exceed that reserved time without making the next client late. For this reason, arriving after your appointment time may result in loss of time from your massage so that your session ends at the scheduled time. Full service fees will be charged even when sessions are shortened due to late arrival. In return we will do our best to be on time, and if we are unable to do so we will add time to your session to make up for our late arrival or adjust the service charge accordingly.
Cancellation Policy
*
I agree
We respectfully ask that you provide us with a 24 hour notice of any schedule changes or cancellation requests. Please understand that when you cancel or miss your appointment without providing a 24 hour notice we are often unable to fill that appointment time and we have scheduled a therapist specifically for that session. These are managed separately from our ‘No appointment’ clients. We understand that schedules can be difficult and that is why we offer a ‘No appointment’ service. Rather than charge a cancellation fee, we will recommend that you come in for a ‘No appointment’ service, as we will not rebook a late cancelled scheduled appointment or a no-show for a minimum of 3 months.
We understand that emergencies can arise and illnesses do occur at inopportune times. If you have a fever, a known infection, or have experienced vomiting or diarrhea within 24 hours prior to your appointment time, we request that you cancel your session. Inclement weather may also result in the need for late cancellations. We will do our best to give advanced notice if we are closing or need to cancel due to bad weather and we ask you to do the same. Please do not risk your own safety trying to make your appointment. Late cancellation due to emergency, illness, or inclement weather will generally not result in any actions, but this is determined on a case-by-case basis.
Inappropriate Behavior Policy
*
I agree
Massage therapy is for relaxation and therapeutic purposes only. There is absolutely no sexual component to massage whatsoever. Any insinuation, joke, gesture, conversation, or request otherwise will result in immediate termination of your session and a refusal of any and all services in the future. You will be charged the full service fee regardless of the length of your session. Depending on the behavior exhibited we may also file a report with the local authorities if necessary. Treat your therapist with respect and dignity and you will be treated the same in return.
Signature (Parent or guardian, if client under 18)
*
Clear Signature
Note:
If you hit submit and the page hangs, does not complete, do not worry. Sometimes it comes through anyway, but we would appreciate if you try again. If not, we do have a kiosk in store and paper forms if necessary. Thank you!
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