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Form

First Time Massage Clients

Transcendence Massage & Yoga LLC

First Time Massage Client Form

First name

Last name

Email

Phone

Birthday

Month

Day

Year

Address

Have you ever had surgery?

Have you ever had an accident?

Long answer

Are You Pregnant?

Do you have any cardiac concerns?

Aneurysms

Deep Vein Thrombosis

Heart Attack

High Blood Pressure

Any skin conditions?

Eczema

Oral Herpes

Other Herpes

Psoriasis

Any neurological conditions?

Seizures

Stroke

Any implanted medical devices?

Long answer

Currently experiencing feelings of illness?

Gastrointestinal conditions?

Coeliac Disease

Hernia

Parasitic Disease

Ulcers

any other health conditions not covered in form

Here at Transcendence, we deal with many people everyday. To keep healthy and to protect high risk people we wear masks. To help keep people healthy we ask if are clients are willing to wear a mask while face up on the massage table. We only ask, we don't require clients to wear masks. Once face down client are welcome to take their mask off. We don't want to put anyone on the spot, so we have included this question on the form. Once you answer this question you will never be asked again.

Are you willing to mask face up?

Yes

Yes but I need a mask provided

No

Disclosure:

By checking this box I agree that I have listed all medical conditions to the best of my knowledge. If found that I have misrepresented any health conditions which leads to a complication I agree to hold myself, not Transcendence Massage & Yoga LLC, liable.

By checking this box I agree that I understand that the massage I receive is provided for the basic purpose of relieving muscular tension, relieving pain and facilitating range of motion and relaxation. If I experience any pain or discomfort during the session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort.

By checking this box I agree that I understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment. I understand that massage therapists are not qualified to perform 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.

By signing this form I confirm my consent to treatment. In addition, I intend this consent to cover the treatment discussed with me and such additional treatment as performed by my massage therapist from time to time to deal with my physical condition for which I have sought massage therapy. I understand that at any time I may withdraw my consent and massage therapy will be stopped.

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Date

Month

Day

Year

Advanced Treatment Consent

First name

Last name

Contraindicated Medical Conditions for Advanced Treatments:

Pregnancy
Blood clot(s)
Diabetes
Neuropathy
Inflammatory skin conditions
Autoimmune condition (MS, Lupus, RA, etc.)
Open wounds or sores
Peripheral vascular disease
Hypotension or Hypertension
Heat sensitivity
Cancer (with or without treatment)
Compromised immune system
Varicose veins
Edema or Lymphedema
Under the influence of drugs or alcohol
Cardiovascular disease

I understand the information contained on this form and confirm that I do not have any of the above conditions.

I understand that my pre-existing medical conditions contraindicate me for advanced massage treatments including but not limited to cupping, hot stones, and/or LED. I take full responsibility for any and all complications which may happen due to utilizing this treatment.

I have researched the advanced treatments and are aware of the risks of each treatment offered.

I waive all liability of Transcendence Massage & Yoga LLC and/or the LMT who performed the treatment who is proceeding in good faith with this treatment in accordance to the information I have provided.

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