Restorative Touch Massage Studio

                Client Intake Health Forms & Client Waiver

                         DATE:______________

Name ________________________________________________________Phone___________________________Text: Y or N

Address:______________________________________________________Email_____________________________________

DOB______________Occupation______________________How did you hear about RTMS?____________________________

Emergency Contact________________________________________________Phone__________________________________

 Permission to Contact

  1. On occasion we will email you with news and specials about RTMS. Permission to contact? yes no

                                                                

Massage Information:

Have you had a professional massage before? yes no

What type of massage are you seeking? RelaxationTherapeutic- What pressure do you prefer? Light Medium Deep

Are you sensitive to any fragrances, oils or creams? yes no Explain_____________________________________________

Are there any areas (feet, face, abdomen, etc.) you do not want massaged? yes____________________________________

What are your goals for today?_____________________________________________________________________________                                                        

Health Information                                         

Do you suffer from chronic pain? yes no If yes, please explain ________________________________________________

  Grief Massage- Any Physical Symptoms_______________________________________________________________________

Are you taking any medications? yes no - If yes please list - also can list on back of page Medication:____________________________Purpose:___________________________________________________________

Medication:____________________________Purpose:___________________________________________________________

Medication:____________________________Purpose:___________________________________________________________

Please indicate any condition you have had in the past or currently have.

Musculoskeletal                                                 Circulatory & Respiratory                           Skin-Current/Other

Joint Replacement(s)                                     COVID-19:Date_______                         Allergies-Current Symptoms?

Headaches/Migraines                                    Heart Condition                                      Rashes

Arthritis                                                            Stroke                                                        Athlete's Foot

Spinal Issues                                                    High/Low Blood Pressure                       Herpes Simplex

TMJ/Jaw pain                                    Lymphedema                                                       Infectiousness Skin Conditions                          

Osteoporosis                                                           Thrombosis/Blood Clots/DVT                Toe Fungus/Warts                        

Tendinitis/Bursitis                                           Varicose Veins                                          HIV/AIDS

OTHER:                                                                  Autoimmune Conditions                        Pregnant

Diabetes   Recent Surgery                         Depression Anxiety/Stress                 Cancer/Tumors

Other:_________________________________________________________________________________________________________________________________________________________________________________________________________

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    ~ Please list any other comments regarding your health/well being ~

NOTE - Massage is not appropriate care for infectious or contagious illness.

      COVID-19 Protocol Questions

Have you had a fever in the last 24 hours- 14 days of 100°F or above? Yes ☐ No ☐ When:____________________________

In the last 14 days have you  had any respiratory or flu symptoms, sore throat, coughing or shortness of breath? Yes ☐ No ☐

In the last 14 days have you had any chills, new muscle aches, new loss of taste or smell. Rashes, spots, lesions Yes ☐ No ☐

Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has had coronavirus-type symptoms? Yes ☐ No ☐ Have you traveled outside Massachusetts  in the last 14 days, Yes ☐ No ☐ ______________________
                                                                                                                                                                                                                                                                                                                                                                                           

Please X any areas of discomfort/stiffness/tension/pain                                                               NOTES On Pain Areas:           

                               

                                         Restorative Touch Massage Studio - Client Waiver

 I,_________________________________, understand that massage therapy given to me by Pamela Chiasson,LMT is intended to

 enhance relaxation, reduce pain caused by muscle tension, help Increase range of motion, and offer a positive experience of touch.

 The general benefits of massage, possible massage contraindications & the massage plan have been explained to me. I understand

 that massage therapy is not a substitute for medical treatment or medications, and that it is recommended that I am concurrently

 working with my Primary Doctor for any condition I may have. I am aware that the massage therapist does not diagnose illness or

 disease, prescribe medications or supplements and that spinal manipulations are not part of massage therapy.

    I have informed the massage therapist of all my known physical conditions/symptoms, medical conditions and medications. I have

     stated all conditions that I am aware of and this information is true and accurate. I will inform the MT provider of any changes in my status. I

    give my consent to receive treatment from this practitioner.

 

   UPDATED COVID-19 Waiver Information-I I also understand, because massage therapy work involves maintained touch and close

   physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. By

   signing this form, I acknowledge that I am aware of the risks involved from receiving treatment, I voluntarily agree to assume those

   risks and I release and hold harmless Pamela Chiasson/Restorative Touch Massage Studio from any claims related thereto.

     Cancellation and No-Show Policy - New Cancellation policy - Amid the ongoing uncertainty of COVID-19, we have modified our

    cancellation policy to offer greater flexibility to all our clients. We hope this will alleviate any stress and hesitation you have about an

    upcoming appointment. If you need to reschedule for whatever reason, and especially if you are not feeling well, we understand &

    request for you to please contact us as soon as possible to reschedule. To further support you, there will be no penalties for
   cancellations at this time. NO SHOWS will be charged 100%.

  Behavior Policy - RTMS is a professional practice following a strict code of ethics. Massage therapy is for relaxation and  

  therapeutic purposes only. RTMS reserves the right to end the session at any time.

Client’s Signature__________________________________________________________________________ Date_____________________

                                                 Restorative Touch Massage Studio - 43 Broad Street #310B - Hudson MA 01749 - 978.852.0270