Massage Intake Form

Sunny Massage
Personal Information
Services
body massage
30mins
60mins
90mins
120mins
combo massage
30mins
60mins
90mins
foot massage
30mins
60mins
chair massage
10mins
20mins
30mins
add:
hot stone
rose oil
Coconut oil
another
Medical Information
Are you taking any medications? yes no
Are you currently pregnant? yes no
Do you suffer from chronic pain? yes no
Have you had any orthopedic injuries? yes no
Please indicate any of the following that apply to you:
Cancer
Fibromyalgia
Headaches/Migraines
Stroke
Arthritis
Heart Attack
Diabetes
Kidney Dysfunction
Joint Replacement(s)
Blood Clots
High/Low Blood Pressure
Numbness
Neuropathy
Sprains or Strains
Massage Information
Have you had a professional massage before? yes no
What type of massage are you seeking?
Relaxation Therapeutic/Deep Tissue
What pressure do you prefer?
Light Medium Deep
Do you have any allergies or sensitivities? yes no
Are there any areas (feet, face, abdomen, etc.) you do not want massaged? yes no
Please circle any areas of discomfort
Body Diagram
Customer Service Consent Agreement

This Customer Service Consent Agreement ("Agreement") is entered into by and between Sunny Massage, located at [Address], and the undersigned client ("Client"). By signing this Agreement, the Client consents to receive services from Sunny Massage and agrees to the following terms and conditions:

1. Scope of Services: The Client consents to receive massage, facial scalp treatment, and facial services provided by Sunny Massage. The Client acknowledges that these services are for relaxation and wellness purposes only and are not a substitute for medical treatment.

2. Assumption of Risk: The Client acknowledges that there are inherent risks associated with massage, facial scalp treatment, and facial services. The Client voluntarily assumes all risks, including but not limited to, physical injury, allergic reactions, or any other adverse effects that may result from these services.

3. Medical Conditions: The Client agrees to disclose any medical conditions, allergies, or medications that may affect the services provided. The Client understands that failure to disclose such information may increase the risk of adverse effects and releases Sunny Massage from any liability arising from undisclosed conditions.

4. Release of Liability: The Client releases and holds harmless Sunny Massage, its owner, employees, and contractors from any and all claims, demands, damages, or causes of action arising out of or connected with the services provided, except in cases of gross negligence or willful misconduct.

5. Indemnification: The Client agrees to indemnify and defend Sunny Massage, its owner, employees, and contractors against any claims, damages, liabilities, and expenses (including reasonable attorney's fees) arising from the Client's breach of this Agreement or any negligent or wrongful act by the Client.

6. Cancellation Policy: The Client agrees to adhere to Sunny Massage's cancellation policy, which requires [number of hours/days] notice for cancellations or rescheduling. Failure to provide such notice may result in a cancellation fee.

7. Governing Law: This Agreement shall be governed by and construed in accordance with the laws of the State of [State]. Any legal action or proceeding arising under this Agreement shall be brought exclusively in the courts of [County], [State].

8. Draping, Boundaries, and Right to Stop

  • The massage therapist will drape the breasts of all female clients. Sunny Massage does NOT perform breast massage.
  • The genital area and gluteal cleavage will remain draped at all times for every client.
  • If the client is uncomfortable for ANY reason, the client may ask the massage therapist to stop the massage, and the therapist WILL end the massage session.
  • The massage therapist may end the massage session if the therapist feels uncomfortable for any reason.
  • The massage therapist MUST immediately end the session if the client initiates any verbal or physical contact that is sexual in nature. Sexual comments, requests, or conduct are prohibited.

9. Health Information and Consent

Massage is intended for relaxation and relief of muscular tension; it is not a diagnosis or substitute for medical care. I have disclosed relevant health conditions and understand that I may ask questions, decline any technique, or withdraw consent at any time. Potential effects include temporary soreness, skin irritation, or allergic reaction. No particular result is guaranteed.

10. Acknowledgment and Signatures

By signing, the client and massage therapist agree to the SPECIFIC services, techniques, and body areas documented above for this session, including the areas to be avoided and the boundaries stated here.

When This Consultation Must Be Completed / Updated

Complete before the client’s first massage session. Review and update whenever the reason for seeking massage changes or the planned techniques, body areas, or breast-massage policy changes. Both parties must sign the updated consultation. Sunny Massage does not provide breast massage; if that policy ever changes, separate written consent before each such session is required.

Office use: First visit Updated consultation Client file/reference:
Consultation Document Checklist
Checklist for Ensuring that a Massage Therapy Consultation Document Meets the Minimum Requirements Established by Rule
The consultation document includes:
1. The type of massage therapy services or techniques the licensee anticipates using during the massage therapy session.
2. The parts of the client's body that will be massaged or the areas of the client's body that will be avoided during the session, including indications and contraindications. (This section/area needs to indicate the actual parts of the client's body that will be massaged or areas to be avoided. Avoid using words like "may/could include the following areas...")
3. A statement that the licensee shall drape the breasts of all female clients and not engage in breast massage of female clients unless the client gives written consent before each session involving breast massage. (You may include a statement that breast massage will NOT be performed, or if it is a modality you will be using, that written approval is needed.)
4. A statement that draping of the genital area and gluteal cleavage will be used at all times during the session for all clients.
5. A statement that if uncomfortable for any reason, the client may ask the licensee to cease the massage and the licensee will end the massage session. (Indicating that the massage therapist will adjust the pressure being used is not the same as ending the session.)
6. A statement that the licensee may end the massage session if the licensee feels uncomfortable for any reason.
7. A statement that the licensee must immediately end the massage session if a client initiates any verbal or physical contact that is sexual in nature.
8. The signature of both the client and the licensee (signatures agreeing to the services the consultation document indicates will be provided during the massage session.)
This consultation document is used:
1. prior to a client's first massage session;
2. if the client's reason for seeking massage changes at any time and/or any of the information in 1-3 above changes; and
3. every time breast massage will be performed unless written consent is received on a separate document.