Patient Forms

Patient Forms

Patient Forms

Please fill out the Client Health form below! Required for all patients. Please answer every question. If you don’t have an answer write N/A.

Health Form (required)

Hot Stone Consent

Health Intake Form
(required for all clients)

Massage History/Treatment Information

Massage History/Treatment Information

Previous History (Past 12 Months)

Previous History (Past 12 Months)

Health History

Musculoskeletal
Circulatory
Respiratory
Nervous
Reproductive
Skin
Digestive
Other

Massage Policies and Guidelines

Draping Policy: Clients will be appropriately draped with a sheet or towel at all times. Only areas being worked on will be exposed. Breast and genital areas are never exposed or massaged.

Professional Standards: Only therapeutic massage services are provided. Sessions will be terminated immediately in cases of inappropriate conduct, harassment, threatening behavior, sexual advances, or disrespect. Full payment is required if a session is terminated for these reasons.

Health and Medical Conditions:

  • Clients must inform the therapist of current treatments, medical conditions, and updates. A doctor’s note is required for clients undergoing chemo or radiation therapy (within the past 12 months).

  • First-time clients should arrive 15 minutes early to complete forms. Returning clients may wait in the reception area if early.

Session Timing: Sessions begin and end at the scheduled time. Late arrivals will still end at the scheduled time, and the full fee will apply.

Cancellation Policy:

  • Cancel at least 24 hours in advance to avoid a fee.

  • Cancellations with less than 24 hours' notice will be billed 50% of the service price.

  • Same-day bookings canceled within 4 hours of the appointment are also subject to a 50% fee.

  • No-shows will be charged the full price. Exceptions for emergencies, illness, or inclement weather are at the therapist’s discretion.

Substance Use: Clients under the influence of drugs or alcohol will not receive services.

Hygiene: Clients are expected to shower on the same day before their session and avoid heavy meals 2 hours prior.

Environment: This is a non-smoking, odor-neutral office.

Privacy: Client confidentiality is always maintained.

Therapist Scope: Therapists only perform services within their licensed practice. Clients with conditions outside this scope should consult their doctor.

Emergencies and Illness: Clients with contagious conditions or signs of infection (e.g., fever, sore throat) must reschedule. Notify the therapist promptly.

Massage Policies and Guidelines

Consent and Contract for Care:

It is my choice to receive massage therapy and I give my consent to receive treatment. I have completed this form to the best of my knowledge and will inform the massage therapist of any change in my physical health.

I understand that a massage therapist cannot diagnose illness, disease, or any other medical, mental, or emotional disorder. Nor do they prescribe medical treatment, pharmaceuticals, or perform spinal thrust manipulations. I realize that the treatment is being given for the well being of my body, mind and spirit. This includes stress reduction, relief from muscular tension, spasm or pain, also for increasing circulation or energy flow. I agree to communicate with my practitioner any time I feel like my wellbeing is compromised. I acknowledge that massage is not a substitute for medical examination or diagnosis; I am responsible for consulting a qualified physician for any physical ailments that I have.

I understand that massage therapy is a therapeutic health aide and is non-sexual.

By typing my full name and 'Accepting' below I acknowledge this contract.

Consent and Contract for Care:

Consent and Contract for Care:

It is my choice to receive massage therapy and I give my consent to receive treatment. I have completed this form to the best of my knowledge and will inform the massage therapist of any change in my physical health.

I understand that a massage therapist cannot diagnose illness, disease, or any other medical, mental, or emotional disorder. Nor do they prescribe medical treatment, pharmaceuticals, or perform spinal thrust manipulations. I realize that the treatment is being given for the well being of my body, mind and spirit. This includes stress reduction, relief from muscular tension, spasm or pain, also for increasing circulation or energy flow. I agree to communicate with my practitioner any time I feel like my wellbeing is compromised. I acknowledge that massage is not a substitute for medical examination or diagnosis; I am responsible for consulting a qualified physician for any physical ailments that I have.

I understand that massage therapy is a therapeutic health aide and is non-sexual.

Massage Policies and Guidelines

Draping Policy: Clients will be appropriately draped with a sheet or towel at all times. Only areas being worked on will be exposed. Breast and genital areas are never exposed or massaged.

Professional Standards: Only therapeutic massage services are provided. Sessions will be terminated immediately in cases of inappropriate conduct, harassment, threatening behavior, sexual advances, or disrespect. Full payment is required if a session is terminated for these reasons.

Health and Medical Conditions:

  • Clients must inform the therapist of current treatments, medical conditions, and updates. A doctor’s note is required for clients undergoing chemo or radiation therapy (within the past 12 months).

  • First-time clients should arrive 15 minutes early to complete forms. Returning clients may wait in the reception area if early.

Session Timing: Sessions begin and end at the scheduled time. Late arrivals will still end at the scheduled time, and the full fee will apply.

Cancellation Policy:

  • Cancel at least 24 hours in advance to avoid a fee.

  • Cancellations with less than 24 hours' notice will be billed 50% of the service price.

  • Same-day bookings canceled within 4 hours of the appointment are also subject to a 50% fee.

  • No-shows will be charged the full price. Exceptions for emergencies, illness, or inclement weather are at the therapist’s discretion.

Substance Use: Clients under the influence of drugs or alcohol will not receive services.

Hygiene: Clients are expected to shower on the same day before their session and avoid heavy meals 2 hours prior.

Environment: This is a non-smoking, odor-neutral office.

Privacy: Client confidentiality is always maintained.

Therapist Scope: Therapists only perform services within their licensed practice. Clients with conditions outside this scope should consult their doctor.

Emergencies and Illness: Clients with contagious conditions or signs of infection (e.g., fever, sore throat) must reschedule. Notify the therapist promptly.

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Hot Stone Massage Consent

Hot Stone Massage Consent

Hot Stone Massage Consent

I consent to hot stone massage by the named therapist or any associated therapist now or in the future. I understand this involves heated stones being placed on or used to massage my body, with the intent to relax muscles.

I acknowledge that while hot stone massage is generally safe, it carries risks such as burns or scarring due to unpredictable heat transfer. Even with proper care, burns may occur without immediate visual signs. I understand that certain medical conditions, like diabetes or poor circulation, may increase these risks. Reduced sensitivity to heat or circulation issues could lead to unnoticed burns.

I also recognize that skin type and medications can affect my risk. For instance, Fitzpatrick Scale Skin Types I and VI carry specific sensitivities to burns and scarring. I accept it is my responsibility to inform my therapist of any conditions or medications that may heighten my risk.

While the therapist will use their best judgment, I understand that outcomes are not guaranteed, and unforeseen risks may arise. By signing, I confirm that I have read and understood this consent, have had an opportunity to ask questions, and agree to hot stone therapy now and in the future.

I consent to hot stone massage by the named therapist or any associated therapist now or in the future. I understand this involves heated stones being placed on or used to massage my body, with the intent to relax muscles.

I acknowledge that while hot stone massage is generally safe, it carries risks such as burns or scarring due to unpredictable heat transfer. Even with proper care, burns may occur without immediate visual signs. I understand that certain medical conditions, like diabetes or poor circulation, may increase these risks. Reduced sensitivity to heat or circulation issues could lead to unnoticed burns.

I also recognize that skin type and medications can affect my risk. For instance, Fitzpatrick Scale Skin Types I and VI carry specific sensitivities to burns and scarring. I accept it is my responsibility to inform my therapist of any conditions or medications that may heighten my risk.

While the therapist will use their best judgment, I understand that outcomes are not guaranteed, and unforeseen risks may arise. By signing, I confirm that I have read and understood this consent, have had an opportunity to ask questions, and agree to hot stone therapy now and in the future.

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