New Client Intake Form | Circle Massage

New Client Intake

First name

Last name

Birthday

Phone

Street Address

City

Region/State/Province

Postal / Zip code

Reffered by

Massage History

Do you currently have a pain or injury problem in your body?

Where have you had pain or injuries in your body in the past?

Have you seen a physician about this problem? If yes, what was/is the diagnosis?

Have you had any surgeries I should know about?

Do you have any other medical conditions I should be aware of?

Are you pregnant?

Is there any part of your body you don't want to receive work on?

Do you take any medications regularly that might make your body tissues more unstable, weak, easily bruised, or that interfere with sensation or pain perception?

What are your main areas causing pain or discomfort?

What would you like to gain from massage?

Policies and Informed Consent

I understand payment is required at the time of service. In-person payments are cash only. Cash payments are encouraged to keep my money local.

I will give 24-hour notice of cancellation and rescheduling. Refund cannot be guaranteed if cancellation occurs within 24 hours of my appointment.

I will arrive 15 minutes early if it will be my first massage to discuss any specifics I was not able to express in the New Client Intake.

If I arrive late to my appointment the massage will occur in the remaining time at the full initial price.

I understand that if I am purchasing a package it does have an expiration date.

If I do not use all of the sessions in my package by the expiration date, I understand I am forfeiting those sessions and will not be refunded.

I understand this massage is intended for the relaxation of the muscular, nervous, and organ systems and not to treat any underlying disease.

I understand that I am in control of my massage and I can pause or stop the massage at any time for any reason. I understand that I am encouraged to give feedback about pressure, areas I would like more focus on, and any concerns or thoughts that arise about the techniques or treatment being used. I understand that I may undress completely or partially according to my comfort level. I understand that any sexual behavior or conversation, on my part or the therapist's is strictly prohibited, will lead to the immediate end of care, and will be reported immediately to the Federation of State Massage Therapy Boards, (Phone: (913) 681-0380; Email: info@fsmtb.org) and the appropriate authorities.

I understand that any information I give is confidential and my massage therapist intends to use this information to provide me with the best treatments that meet my needs. I understand it is important to stay hydrated and fed after the massage.

I have read and accept the polices and informed consent

Your Signature