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

Layout

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 *

Layout

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)

Face Massage Desired? *

Is a Breast/Chest Pillow required?

Interested in CBD Products?

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

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, Tested Positive For COVID Or Have You Been Around Anyone Testing Positive for COVID In The Last Week? *

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

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 or you can have $10 cash

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.