• Massage Intake Form

    All information is held confident. At no given point is information disclosed or shared without client’s written consent. 
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Appointment*

  • Referral

  • Health Information

  • Medications
  • Allergies
  • 4. Frequency
  • 5. At what time of day is the pain at its worse?

  • Please check any symptoms that apply:

  • Head Symptoms
  • Neck Symptoms
  • Shoulders Symptoms
  • Arms & Hands Symptoms
  • Mid-Back Symptoms
  • Low Back Symptoms
  • Hip Symptoms
  • Legs and Feet Symptoms

  • Client information are confidential and written authorization is required to release any information.

    We do not double book appointments

    Please reschedule session if more than 15 minutes late

    24 hour cancellation notice is required 

    All Deposits Are NON REFUNDABLE and will be used towards the balance of services rendered on the day of appointment. 

    No Call No Shows Will Result In Full Payment Of Your Spa Session To Be Processed From Credit Card Information Provided during confirmation call. 

    You will be draped and at no time be exposed

    You will have a consultation with your therapist to discuss the session

    You my end the session at any time for any reason. Ending the session early will still result in FULL payment Of Services booked. 

    Inappropriate behavior will NOT be tolerated and may be prosecuted to the full extent of the law

     

    Disclosure and Informed Consent

    I understand that massage and bodywork are wellness and therapeutic services and are not a substitute for medical diagnosis, medical treatment, or emergency care. I agree to provide complete and accurate health information and to notify my therapist of any change in my health, medications, injuries, surgeries, pregnancy/postpartum status, or medical restrictions.

    I understand that the therapist may modify, stop, postpone, or decline treatment if information or circumstances indicate that treatment may be inappropriate or unsafe. I agree to communicate discomfort, pain, dizziness, numbness, or other concerning symptoms during the session.

    I understand that no specific outcome or result is guaranteed. I authorize Healing Touch Therapy Spa to provide the services I request after discussion with the therapist.

    I further understand and agree that Healing Touch Therapy Spa and its staff are not liable for falls or injuries while getting on, off, or walking around the mobile spa.

    A non-refundable deposit is required in order to be fully confirmed on the books. The deposit starts at $50 and may increase depending on location, number of people, and services rendered. The Deposit goes towards the balance of services rendered on the day of or before your appointment.

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