Patient Forms

Please fill out the Client Health form below! REQUIRED FOR ALL NEW PATIENTS. Please answer every question. If you don’t have an answer, write N/A.

Health Intake Form
(required for all clients)

            1
          
              Health Intake Form
              
            2
          
              Massage History/Treatment Information
              
            3
          
              Health History
              
            4
          
              Signature

Full Name

Address

Phone Number

Massage History/Treatment Information

List your past massage sessions and/or experiences.

Primary Care Provider (if any)

Have you ever had a professional massage?

May we consult with your primary care provider?

What results do you want from your sessions?

Please tell us of any areas of your body where you would prefer to NOT receive a massage:

Prioritize some areas of your body that you prefer to be massaged

Are you currently seeing a healthcare practicioner?

Are you currently seeing a Counselor, Psychotherapist, or a Support Group?

List Stress Reduction and Exercise Activities. Please include frequency:

List current Medications, Herbals & Supplements and reason for use. Please include OTCs such as aspirin, ibuprofen, Claritin, etc.

I Accept These Terms - 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.

I Accept These Terms - Consent and Contract for Care:

I, the undersigned, voluntarily consent to receive massage therapy services from the licensed massage therapist(s) at Therapeutic Healing and Bodywork, I understand and agree to the following:

Purpose of Massage: The primary objectives of massage therapy include stress reduction, relief from muscular tension, spasm or pain, and enhancement of circulation or energy flow.
Scope of Practice: I acknowledge that massage therapists are not qualified to diagnose illnesses, diseases, or any other medical, mental, or emotional disorders. They do not prescribe medical treatments or pharmaceuticals, nor do they perform spinal thrust manipulations.
Communication: I commit to informing the therapist of any changes in my physical health and agree to communicate any discomfort or concerns during the session.
Medical Consultation: I recognize that massage therapy is not a substitute for medical examination or diagnosis. It is my responsibility to consult a qualified physician for any physical ailments I may have.
Professional Boundaries: I understand that massage therapy is a therapeutic health aide and is strictly non-sexual.

Consent for Hot Stone Massage:

In addition to the general consent above, I specifically consent to receive hot stone massage therapy and understand the following:

Nature of Hot Stone Massage: This therapy involves the use of heated stones placed upon or used to massage my body with the intent to relax muscles.
Potential Risks: While generally safe, hot stone massage carries risks such as burns or scarring due to unpredictable heat transfer. Even with proper care, burns may occur without immediate visual signs.
Medical Conditions: Certain medical conditions, like diabetes, poor circulation, or reduced sensitivity to heat, may increase these risks. It is my responsibility to inform the therapist of any such conditions or medications that may heighten my risk.
Skin Sensitivity: I acknowledge that skin type and medications can affect my risk. For instance, specific skin types may have particular sensitivities to burns and scarring.
No Guarantees: While the therapist will use their best judgment, I understand that outcomes are not guaranteed, and unforeseen risks may arise.

Acknowledgment and Release:

By signing below, I confirm that I have read and understood this consent form, have had an opportunity to ask questions, and agree to receive massage therapy, including hot stone therapy, now and in the future. I release [Clinic/Practitioner Name] and its therapists from any liability arising from the services provided.

Signature

Sign digitally using your mouse, touchscreen, or a digital pad.

Patient Forms

Health Intake Form(required for all clients)

Health Intake Form
(required for all clients)