Print and bring with you RESToration Massage by Diana: Intake Form Personal Information: To help us serve your massage needs, please answer the questions honestly. Any information provided is confidential. Name …………………………………………………………………………………………. Address……………………………………………………………………………………… Birth date/ Cell ……………………………………………………………………………………. Email ……………………………………………………………………………………….. How did you hear about me? Referral ? 1. Have you had a professional massage before? 2. Do you have any allergies to oils, lotions, or scents? (If allergic please confirm ahead of time) 3. What are your therapeutic goals for this massage session? Relaxation or working out the kinks? 4. Would you like to add aromatherapy to your session today? ($15- on headrest and applied to lotion) 5.. Would you like to add Extended Rest today? ($20 for 30 minutes of additional time on the table to relax? Medical History: To plan a massage session that is safe and effective, we require some information about your medical history. 6.. Are you currently under a physician’s care? If yes, physician’s name _______________________________ Contact # ( ) ___________ 7. Are you currently taking any medications? If yes, please list and say what they are for ___________________________________________________________________________
8. . PLEASE CIRCLE AND ELABORATE IF IT APPLIES TO YOU. Muscular-Skeletal: Headaches, joint stiffness/swelling, spasms, cramps, broken/fractured bones, sprains, strains, back, neck, hip, arm, shoulder, hand/foot pain, chest, ribs, abdominal pain, TMJ, tendonitis, bursitis, scoliosis, osteoporosis , other……
Circulatory/Respiratory: Dizziness, shortness of breath, fainting, cold feet or hands, stroke, heart conditions, allergies, asthma, high or low blood pressure or other…….
Digestive: Indigestion, constipation, gas/bloating, irritable bowel syndrome or other…..
Reproductive system: Pregnancy (How many weeks? High risk requires doctors note), cysts or other….. Skin: Rashes, allergies, athletes foot, acne, bruises easily, psoriasis, eczema, impetigo, ringworm, scabies, or other… Cancer
If you have any contagious skin conditions like scabies, athletes foot, impetigo, ringworm, basic COLD or FLU, open wounds and have something I would rather not catch, please wait till it clears up before coming in to see me. HIV/AIDS- please let me know if you have any areas that are open cuts, wounds or bleeding, open lesions. Pressure preference: (please circle) Light, Medium, Deep It is your responsibility to inform me if the pressure is too much or too little. If taking any pain killer, it will lessen your ability to feel, and may not be able to feel the amount of pressure being received.
POLICIES: Upon initial visit, please arrive early to fill out the intake form, go over any questions you may have, etc. My massage therapy, a time-dependent practice, is run by appointments. This assures you of your hour massage and that your massage runs on time. If you are late, the appointment will still end at the appointed time, which penalizes you and not the person after you. That is only fair. If you find it necessary to cancel or change your appointment, please allow for 12 hours notice. Any missed appointment with less than 12 hours notice will obligate you to pay for your appointment at the FULL PRICE. Should a substitute be found to fill your appointment , no charge will be made for the missed appointment or last minute notice if filled. I will not double dip, I will try to find a person to fill your spot, and I go out of my way to be fair- and you are expected to do the same. Sleeping in or forgetting isn't considered any emergency, but please remember that this is still a business. Fortunately this policy has not been abused since I have been in practice . In fact, most clients have paid for their missed session (or forfeited a pre paid session in a package). It is embarrassing situation to have to enforce this policy but this is a business. If I cancel with less than12 hours notice I will give you a free 30 minutes of either Swedish or Deep Tissue (depending on massage cancelled). Gift certificates, single sessions and packages are non refundable. You can share massage packages, and also make a session into a gift certificate, I value our relationship and hope we can continue it on a professional and sound basis. Hopefully you benefit from your massage as much as I enjoy having you as one of my clients. I ACKNOWLEDGE THAT THERE ISN’T A WAY TO PRE-PAY OTHER THAN CALLING RESTORATION MASSAGE BY DIANA DIRECTLY, OR BY VENMO. THE CARD ON FILE IS TO SECURE THE APPOINTMENT. PAYMENT IS DUE AT THE END OF THE SESSION. CASH, CHECK, OR VENMO ONLY ( CAN USE A CREDIT CARD ONLY THROUGH VENMO APP-SMALL FEE, DEBIT NO FEES THROUGH THE APP). Massage Consent: I agree to inform my therapist immediately if I experience pain. I certify that I have disclosed all known medical conditions and acknowledge that my therapist is not responsible for the aggravation of any unknown or undisclosed condition. I also acknowledge that this massage is therapeutic and that any inappropriate solicitation of my therapist will result in the immediate termination of my massage without refund. Disclaimers: Draping will be used during all sessions. Minors receiving a massage must be accompanied with a parent during the massage, and women deemed with a high-risk pregnancy needs a doctor’s note. Massage therapists are not qualified to perform spinal adjustments, diagnose, prescribe, or treat any physical or mental illness and nothing said during the session should be construed as such. Deep-tissue and trigger point may cause soreness. Clients are advised to remain hydrated, stretch and apply hot and cold packs as indicated and advised by your physician.
