RoomIntakeForm | Kneading You Massage

NEW CLIENT INTAKE FORM

Step 1 of 2

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number

Email Address

Birthdate (Format xx/xx/xxxx) If You Are Under 18 You Will Need A Signed Consent Form By A Parent or Guardian

Body Size (For Setup Purposes Only)

Table Covering Preferred (Room IS Usually Cool)

Glute Muscle Work Consent

Interested in Dry Skin Brushing? (Prior to Massage)

Foot Massage Desired?

Face Massage Desired?

Is a Breast/Chest Pillow required?

Interested in Pain Relief Products?

What Line Of Work Are/Were You In? (To Help Determine Repetitive Movements)

Which is Your Dominant Side?

Do You Smoke? (If Yes, Please Do Not Smoke Right Before Your Massage)

Are You On ANY Medications? If So Please List Below.

Do You Have ANY Allergies?

Do You Have ANY Skin Issues?

How Long Ago Was Your Last Massage?

What Is Your Main Area Of Concern For This Appointment?

Do You Have ANY Areas To Avoid?

Have You, Yourself, Been Ill Or Have You Been Around Anyone Ill In The Last Week?

Is There Anything Else You'd Like Me To Know? Recent Surgeries/Injuries? Joint replacement?

By which social media platform, search engine or person were you referred to me by?

FYI: If you refer a NEW client to Kneading You Massage I will increase your next massage appointment by 15 minutes.

Should You be Considered for One of These Discounts?

Cancellation Policy

I agree to the Cancellation Policy

I require all clients to provide at least 24-hour notice when canceling or rebooking an appointment. Late cancellations or no-shows will be invoiced for the full session. Clients arriving more than 15 minutes after their appointment start time will be considered a no-show. (Please arrive at least 5 minutes early) I will provide a one-time cancellation fee waiver for extenuating circumstances. Should I need to reschedule with less than 24-hours’ notice due to unforeseen circumstances I will text you immediately and offer you an additional 15 minutes added to your service on rebooked session.

Sexual Misconduct Policy

I agree to the Sexual Misconduct Policy

I, as the client, understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session and will still require full payment for the session.

General Disclaimer

I agree to the General Disclaimer

I, as the client, understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience ANY pain or discomfort during the session I will immediately inform the Therapist so that the pressure and/or tool can be adjusted to my preferred level of comfort. I further understand that massage should not be construed as a substitute for a professional medical examination, diagnosis, or treatment. I understand that Licensed Massage Therapists are not qualified to preform 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 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 Licensed Massage Therapist updated as to any changes in my medical profile upon arrival of my session and understand that there shall be no liability on the Licensed Massage Therapist's part should I fail to do so. I also understand that the Licensed Massage Therapist reserves the right to refuse to perform massage on anyone whom she/he deems to have a condition for which massage is contraindicated.

Consent for Verification

As of July 1, 2024, Florida HB197, requires that your information be verified with your current driver's license upon arrival. I appreciate your cooperation and confirm that only I and a licensed individual from the Department of Health will ever see your information provided.