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First Time Massage Clients

Transcendence Massage & Yoga LLC

First Time Massage Client Form

First name

Last name

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

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.

Signature

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Date

Month

Day

Year