Name (required) *
Primary Phone (required) * Is this a cell phone? (required) * If so, do I have permission to text you at this number? (required) *
I will sometimes text to remind you of your appointment or to reschedule if I have a conflict.
Alternate Phone Date of Birth
* Email (required) *
In case of emergency contact name (required) * Emergency Contact Phone (required) * Relationship to emergency contact (required) * Referred By Your Occupation Your Physician
Please take a moment to carefully read the following information and sign where indicated. If you have a specific medical condition or specific symptoms, massage/bodywork may be contraindicated. A referral from your primary care provider may be required prior to service being provided. All client information is strictly confidential. The information you provide on this intake form is used only by me to better understand and serve the needs of my client. Furthermore, the Texas Department of State Health Services requires a consultation/intake form on every
massage client. Have you ever experienced a professional massage or bodywork session? (required) * If yes, how recently? What is your major complaint or condition you want to improve: (required) *
What are your intentions or expectation for this visit? (required) * What kind of pressure do you prefer? Please check the box if you have any of the following: (required) * Other medical conditions? Are you taking any medications I should know about? Additional comments regarding your health and well - being I would like to be on your email newsletter list to receive valuable massage promotions & healthy living tips! * I, the undersigned, understand and acknowledge that payment for all care received is my responsibility. Payment is due at time of services unless other arrangements have been made in advance with the massage practitioner. Skillful Touch Massage accepts cash or checks. I also understand that at least 24- 48 hours cancellation and rescheduling notice is necessary to avoid last minute/late charges.
I, the undersigned, understand that the massage/bodywork
I receive is intended to enhance relaxation, reduce pain caused by muscle tension, increase range of motion, improve circulation and offer a positive experience of touch. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of
comfort. I further understand that massage or bodywork 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 of which I am aware. I understand that massage/bodywork practitioners 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 should be construed as such. Because massage/bodywork 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 practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner's part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. I have received a copy of the therapist’s policies, I understand and agree to abide by them. Cancellation Policy
I understand that unanticipated events happen occasionally in everyone’s life. In my desire to be effective and fair to other clients, and out of a necessary consideration for my time, the following policy will be honored.
Failure to cancel or reschedule at least 24 hours before the start of the appointment time will result in a full charge of the scheduled massage appointment.
Ideally, you’ll give me closer to 24-48 hours notice when possible. I trust your judgement and consideration. Should I need to apply the cancellation policy, you will be notified by phone, text or through email that payment is required prior to your next scheduled appointment.
HOW TO CONTACT ME
If a true emergency presents itself that conflicts with your appointment, you must notify me immediately through any medium necessary. Call or text me at (210) 705-0644 or email me at firstname.lastname@example.org
It is your responsibility to ensure you have received a reply from me to confirm your cancellation or rescheduling BEFORE your missed appointment time.
If you arrive late, your session may be shortened. You will be charged the full amount of the scheduled session.
Anyone who either forgets or consciously chooses to forgo their appointment for what ever reason will be considered a “no show”. They will be charged for their missed appointment and future service will be denied.
Working with me, you agree to honor this cancellation/rescheduling policy. (signatures will be provided on printed copy)
Client’s Signature Date
Massage Therapist’s Signature Date
This field is for validation purposes and should be left unchanged.