Returning Client Intake Form

Please complete and submit the following form before your appointment date otherwise, you will be required to complete the form onsite before your session.

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First Name        Last Name
Email Address:
 
All information has remained the same since your last appointment Yes No

 
Changes to your contact information
Changes in your health conditions
  
Changes to your preferences
(you may also resubmit a preferences form)

 
Type of massage requesting

Areas to be worked
(If you have a focused or half session please only select the few specific areas that are to be treated)
Please note: Most 60 minute sessions include work on the areas followed by a *.  If you wish to have work done on an area that does not have a star by it, you will either need to upgrade to a longer session, not select one of the starred options below or understand less work will be spent on other areas to include the additional treatment area(s). 
90 minute sessions may select all of the areas below.

I give the massage therapist my permission to work on the following areas of my body:

Focused Session                                                                          

 

Front of Legs*

Scalp

 

Upper Thighs*

Face

 

Back of legs*

Neck/Shoulders/Chest *
(upper area of chest for women/pectoral area included for men)

 

Outer Thighs*

Arms*

 

Feet*

Hands*

 

Gluteus Muscles*

Abdomen

 

Back*

IMPORTANT:
Please enter the areas from above that you did NOT check and therefore want to be avoided.

Any minor injured/cut or bruised areas to work around or avoid? Yes No  

Relax, you’re in good hands!

 

Informed Consent and Massage Policies

I understand that the massage I will be receiving from RelaxAmerica Massage is for the purpose of stress reduction, relief from muscular tension or spasm.  I understand that the massage therapist does not diagnose illness, disease, or any further physical or mental disorders.  As such, the massage therapist does not prescribe medical treatment or pharmaceuticals, nor do they perform spinal manipulations.  I understand that massage is not a substitute for medical treatment or diagnoses and that it is recommended that I see a physician for any physical ailments that I may have. 

I acknowledge that the information I have provided on this form is correct and current to the best of my knowledge. I understand that it is my responsibility to inform the massage therapist of any changes to this information.  I understand that if I experience any unusual discomfort and/or pain during my massage sessions it is my responsibility to inform the massage therapist so that they can adjust the pressure or technique being used.

Privacy Policy- All written records and massage sessions are kept strictly confidential and will not be shared with any outside establishment, individuals, organizations, or medical facilities without explicit written consent from the client (you) or the client’s legal guardian.  Unless legally required by local, state, or federal subpoena, summons, or other court order.

By completing and submitting this form, I confirm my consent to treatment.

Please type your name in the consent box:

In office use:    Client Signature ______________________________________

Sharing the Gift of Relaxation

 

I value your continued enjoyment of my services. Nothing compliments me more than a positive word of mouth recommendation and referrals. To thank you, I offer discounts and special gifts to my clients who allow me to bring my vision of a relaxed America to friends, family and co workers. 

Do you have any friends you feel would benefit and would be interested in receiving a massage
from RelaxAmerica Massage?

 Name   e-mail   Phone    Ext.

Name   e-mail   Phone   Ext.
 

Would you be interested in having RelaxAmerica Massage come to your office for on site massage?

Yes   No  Maybe Later

 If so, please provide contact information of the individual responsible for employee benefits so we may inform them about our unique on site corporate massage packages. 

Name    Title  

Phone  ..  Ext.


 If a health day is booked by your employer, you will receive a gift certificate
for a complimentary massage as our thank you!