Massage Therapy Intake Form (Page 2 of 2) in pdf

Policies & Procedures

We thank you for taking the time to come in today and hope that your bodywork experience is a positive one. Please take note

of the following information and indicate your compliance with these policies by signing and dating below:

•

You must inform your therapist if you have taken any over-the-counter or prescription pain medications or muscle

relaxants within the past 12 hours. Certain medications make it difﬁcult for you to give feedback as to the depth (or

pressure) of massage. It is imperative that your therapist know all the medications you take and the reasons for taking

them. With this knowledge, the therapist can make a judgment as to the type of work you can safely receive. If you are

currently under treatment with narcotic pain medication and/or muscle relaxants, it may not be appropriate for a therapist

to work on you at this time.

•

Any client apparently under the inﬂuence of drugs or alcohol will be asked to reschedule her appointment. Please note

that this may result in accrual of a $20.00 rescheduling fee.

•

We require 24 hours’ advance notice if you need to cancel your appointment. Less than 24 hours’ notice may result in

accrual of an appointment cancellation fee of $20.00, and you may be required to pre-pay before your next appointment.

However, we do understand that situations and emergencies arise that may make it difﬁcult for you to give adequate notice

of your cancellation, and every effort will be made to take these situations into consideration when assessing cancellation

fees.

•

If you arrive late for your appointment and would still like to receive your massage at that time, the length of time for

your session may be shortened based on the time you arrived, and full payment will still be due. You will be advised if

this is going to occur and will be given the option to reschedule your appointment. Please note that this latter option may

result in accrual of a $20.00 rescheduling fee. If you arrive more than 15 minutes late for your appointment, you may

be required to reschedule and may accrue a $20.00 rescheduling fee. This will be at the sole discretion of the massage

therapist.

•

Upon your arrival for your massage session, your therapist will show you to the treatment room and then discuss your

goals for your treatment. Please mention all health issues and problem areas that you have. The therapist can best meet

your needs if she understands them.

•

Once your therapist has left the massage room, undress to your level of comfort. It is our policy that you leave your

underwear on. Ladies, it is preferable to remove your bra, as this makes the shoulders and back more accessible for

massage. You may then lie down on the table and cover up with the top sheet. Your therapist has been trained to keep

you modestly draped at all times, as your privacy and comfort are of utmost importance. Your therapist will knock on the

door and ask if you are ready before entering the room.

•

We ask that you please remove all jewelry and other items prior to your treatment (i.e., watches, glasses, rings, bracelets,

earrings, etc.) and place them safely with your belongings. WE ARE NOT RESPONSIBLE FOR LOST OR MISPLACED

PERSONAL ITEMS.

•

When your session is over, you will be left to dress in privacy. When you leave the room, please leave the door open and

return to the waiting room and reception area.

•

Please be advised that not all massage and bodywork techniques may be appropriate for all clients. There are also some

situations in which any type of massage work is contraindicated (inadvisable). Situations will be evaluated on a case-by-

case basis, and the therapist reserves the right to qualify and limit massage techniques when deemed advisable.

By signing and dating this form, below, you acknowledge your understanding of, and intent to comply with, the above-stated

policies. We hope your experience with us is a positive one and one that you will enjoy often!

Signature: _____________________________________________________ Date: ______________________________

Massage Therapy Intake Form Page 2

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