(571) 481-0093

edna@milkywayhealing.com

Massage Therapy Client Intake Form

Chief Complaint *
Do you exercise regularly and/or participate in any sports? *
YesNo

If yes, which sports?

Have you ever had any injury or surgery? *
YesNo

If yes, describe

Are there any cuts or bruises on your body that I should be aware?. *
YesNo

If yes, describe

What areas of your body you would like me to concentrate today? *
Any area of your body I should avoid? *
Is there any chance you might be pregnant? *
YesNo
Medications/ Allergies *

Health History (circle one per item)

Client/Therapist Agreement and Policy Statement

Statement of Confidentiality:

All information shared between a client and therapist remains confidential except for child and/or elder abuse.

Intoxication

No Bodywork will be given if the client or therapist is in anyway intoxicated. Massage mixed with intoxication can cause serious damage. With prescriptions, please obtain written consent from your doctor or healthcare professional before you show up for your appointment.

Sexual Appropriateness

Sexual behavior by the therapist toward the client or by the client toward the therapist is always unethical and inappropriate. It is always the responsibility of the therapist or health professional to see that sexual misconduct does not occur. Session will end immediately and client will be charged full price should any sexual misconduct take place.

Tardiness/Cancellations

Client will notify the therapist if he/she is running late. If client is more than 10 minutes late the therapist reserves the right to deduct the time from the session and charge full price. When cancelling an appointment it is imperative client calls 24hrs prior to the appointment. You will be charged a cancellation fee of $20.00 if canceling later than 24hrs. This fee will be charged on the credit card number provided by client at the time of the appointment.

Forms of Payment

Cash, Credit and Paypal

Draping

Clients will be asked to undress only to their comfort level. However if client chooses to fully undress, they will be draped with a sheet at all times during the session. The genitals and breasts are never exposed or massaged.

Personal Belongings:

When receiving massage/bodywork, it is important that you remove all of your jewelry so the therapist can freely work the muscles without obstruction. Please make sure to remove watches, necklaces, bracelets, earings, etc. It is the client’s responsibility to collect his/her belongings before leaving the massage room. Therapist is not responsible for any item left behind.

I, (client) understand that this massage will be provided by Edna Ribeiro (therapist) and give him/her permission to do so. The general benefits of massage, possible contraindications and the treatment procedures have been explained to me. I understand that massage therapy is not a substitute for any medical treatment or medications, and that it is recommended that I concurrently work with my primary caregiver for any condition I may have. I am aware that the massage therapist does not diagnose illness or disease, does not prescribe medications. I have informed the massage therapist of all my known physical conditions, medical conditions and medications, and I will keep the massage therapist updated on any changes.

I Agree to Client/Therapist Agreement and Policy Statement

Client's Signature:


Date :