Restorative Touch Massage Studio
Client Intake Health Forms & Client Waiver
Name ________________________________________________________Phone___________________________Text: Y or N
DOB______________Occupation______________________How did you hear about RTMS?____________________________
Permission to Contact
Have you had a professional massage before? ☐yes ☐no
What type of massage are you seeking? ☐Relaxation☐Therapeutic- 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?_____________________________________________________________________________
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:___________________________________________________________
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
~ 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