Massage Intake Forms - Maximized Health Chiropractic (Page 2 of 2) in pdf

Massage Intake Forms

Informed Consent Agreement

By signing, client acknowledges having read and agreeing to all terms of receiving bodywork. Any questions

should be asked prior to receiving massage/bodywork. Client also releases Therapist and Maximized Health

from responsibility for any conditions that may arise during or after receiving massage/bodywork.

General Benefits: Increases in circulation, toxin removal, range of motion, flexibility, energy, heart rate, body

temperature, immunity, body awareness, and relaxation; decreases in discomfort, fatigue, tension, and stress

levels.

General Contraindications: Medical emergencies (shock, hemorrhage, seizure, poisoning, etc.), high fever

(102°F), highly-metastatic cancer, intoxication, pain medications or extreme fatigue (mental or physical).

**Any client under physicians’ care must notify therapist of condition and changes. Working without physician

approval may be detrimental to the physical well-being of the client.

Rates: $70/hour, $45/half-hour, $95/90-minute ~ Base Rates (discounts/packages available) Payment is due

when service is received. Advance payment will be accepted. Cash, checks and credit cards accepted. A fee of

$25 will be charged on any returned check.

Confidentiality: All information/conversation exchanged during a treatment session or about a treatment

session remains confidential for the safety and well-being of client and therapist.

General Etiquette:

-Late clients will have a shortened treatment at the same rate of a full session.

-No shows will be charged for a full treatment session.

-Cancellations one day (24 hours) prior will not be charged - Less notice is charged half.

-Intoxication can have many negative effects on the body when combining massage with alcohol. Client will be

asked to leave and charged full price for a treatment session if found to be intoxicated.

Recommendations: Avoid large meals 90 minutes before a session. Food fresh in the system may have an

adverse effect on the client. For Shiatsu treatments, plan on having time after session for low-key activity or

sleep. Contact lenses may become “dry” during treatment session, bringing a case is suggested.

Right of Refusal: Therapist and client both reserve the right to end a treatment session at any time for any

reason. Therapist will fill out a disclosure statement to inform client why treatment session is ending. Client

does not need to give any reason for ending a treatment session.

Sexual innuendos, language and/or behavior will not be tolerated. Session will end immediately and client will

be charged full price.

Name __________________________________

Signature: ______________________________________

Date: _________________

7384 South Alton Way, Suite B Centennial, CO

Phone: 303.462.4476

Massage Intake Forms - Maximized Health Chiropractic Page 2