Massage Office Policies
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- Barbara Parks
- 5 years ago
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1 Massage Office Policies 1. All appointments are scheduled in advance. 2. Clients are expected to pay for all services at the time they are rendered. We accept cash and debit/credit cards for payment. 3. Cancellations must be done 24 hours in advance or you will be billed $20.00 for a 30 minute scheduled massage or $30.00 for a 60 minute scheduled massage. 4. Please arrive a few minutes early for each session. 5. If this is your first visit, please arrive 15 minutes early to fill out paperwork and discuss treatment with the therapist. 6. If you are late for your massage appointment you will be provided as much time as available within the scheduled time slot. You will, however, still be charged the full amount for your scheduled session. We will not add time to your session because of your tardiness. 7. Sexual misconduct is forbidden. Client understands that any illicit or sexually aggressive remarks, advances or gestures will result in the immediate termination of the session and will be liable for full payment of the scheduled appointment. I have read, understand and agree to the policies listed above. Name (print):_ Signature: Date: Appointment Date: Appointment Time:
2 Client Intake Form Therapeutic Massage Name _ Phone (Day) _ Phone (Eve) Address City/State/Zip _ Date of Birth Occupation Emergency Contact Phone The following information will be used to help plan safe and effective massage sessions. Please answer the questions to the best of your knowledge. Date of Initial Visit 1. Have you had a professional massage before? Yes No If yes, how often do you receive massage therapy? 2. Do you have any difficulty lying on your front, back or side? Yes No 3. Do you have any allergies to oils, lotions or ointments? Yes No 4. Do you have sensitive skin? Yes No 5. Are you wearing contact lenses ( ) dentures ( ) a hearing aid ( )? 6. Do you sit for long hours at a workstation, computer or driving? Yes No If yes, please describe
3 7. Do you perform any repetitive movement in your work, sports or hobby? Yes No If yes, please describe 8. Do you experience stress in your work, family or other aspect of your life? Yes No If yes, how do you think it affected your health? muscle tension ( ) anxiety ( ) insomnia ( ) irritability ( ) other 9. Is there a particular area of the body where you are experiencing tension, stiffness, pain or other discomfort? Yes No If yes, please identify 10. Do you have particular goals in mind for this massage session? Yes No 11. Are there any specific areas you would like the massage therapist to concentrate on during this session? Yes No If yes, please identify Medical History In order to plan a massage session that is safe and effective, I need some general information about your medical history. 12. Are you currently under medical supervision? Yes No 13. Do you see a chiropractor? Yes No 14. Are you currently taking any medication? Yes No If yes, please list _ 15. Please circle any condition listed below that applies to you: contagious skin condition open sores or wounds easy bruising recent accident or injury recent fracture artificial joint sprains/strains phlebitis deep vein thrombosis/blood clots joint disorder/rheumatoid arthritis/oseteoarthritis/tendonitis osteoporosis epilepsy headaches/migraines cancer
4 current fever diabetes swollen glands allergies/sensitivities heart condition high or low blood pressure circulatory disorder varicose veins Please explain any condition that you have marked above back/neck problems Fibromyalgia TMJ carpal tunnel syndrome tennis elbow pregnancy If so, how many months? Is there anything else about your health history that you think would be useful for your massage practitioner to know to plan a safe and effective massage session for you? Draping will be used during the session-only the area being worked on will be uncovered. Clients under the age of 17 must be accompanied by parent or legal guardian during entire session. Informed written consent must be provided by parent or legal guardian for any client under the age of 17. I, (print name) understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe or treat any physical or mental illness and that nothing said in the course of the session given will be construed as such. Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on he therapist s part should I fail to do so. Signature of client _ Date Signature of Massage Therapist _ Date Dr. Notes: _
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