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].

I hereby understand that:

8. The treatment I receive is for the basic purpose of relaxation and relief of muscular tension.

9. Any illicit or sexually suggestive remarks or advances will result in immediate termination of the treatment.

10. Sunny Massage keeps rights not to provide service to the customers who we believe had/will have improper action.

11. 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.

12. Draping of the genital area and gluteus cleavage will be used at all times during the session for all clients.

13. The licensee must immediately end the massage session if a client initiates any verbal or physical contact that is sexual in nature.

14. If the client is uncomfortable for any reason, the client may ask the licensee to end the massage, and the licensee will end the session. The licensee also has a right to end the session if uncomfortable for any reason.

By signing below, the Client acknowledges that they have read, understood, and agree to the terms and conditions of this Agreement.

This Agreement constitutes the entire understanding between the parties and supersedes all prior discussions or agreements regarding the subject matter herein.