Welcome to Freedom Massage. We look forward to working with you. Please note: In order to receive a massage with us you will need to completely fill out this form. Each section is important in order for us to provide you with a great session and uphold state wide ethics for massage therapists.
Please Type Your First and Last Name *
Your answer
Email *
Your answer
Phone Number *
Your answer
Address *
Your answer
Date of Birth *
Your answer
Emergency Contact Name and Phone Number *
Your answer
How did you hear about Freedom Massage? *
Your answer
Have you ever had a massage before? *
Your answer
If yes, how often do you get massages? *
Your answer
What is your preferred level of conversation during your massage? (Please note: your therapist may ask about pressure during your session) *
How frequently do you exercise? *
Do you regularly stretch? *
Medical Information:
Recent Surgeries? List
Your answer
Current Medications? List
Your answer
Areas you currently feel are tense on your body and need special attention:
Are there areas you prefer we do not work on? Please list: *
Your answer
Do you want your glutes worked on (buttocks)? *
If time permits, would you like your abs worked on? *
So we can give you the help, care, and support you deserve, please let us know anything else you think is important in regards to your health:
Your answer
Client must review the following:
Please carefully read below. Please note —answering yes works as your signature and validates you are responsible to share important/additional health information with your therapist today and at all appointments in the future:

I have stated all conditions I am aware of, and this information is true and accurate to the best of my knowledge. I will inform my health care provider and massage therapist if anything changes in my status.

If I experience any pain or discomfort, I will immediately inform my massage therapist so that the pressure and/or
methods can be adjusted to my comfort level.

If there is something I feel I need and I am not getting during a session I understand it is best to let the therapist know during the session, rather than leaving disappointed.

I acknowledge that massage is not a substitute for a medical examination or diagnosis and that I should see my health care provider for those services.

Verbal or physical conduct of a sexual nature will constitute as sexual harassment it will be reported to the authorities and will absolutely not be tolerated.

Therapists should not be asked for personal information or be contacted outside of Freedom Massage. Our code of ethics does not support it in the state of PA.

I hereby hold harmless and indemnify the therapist, their principals, and Freedom Massage from all claims and liability regarding massage whatsoever.

If a client is not feeling well or foresees a potential missed appointment they must give Freedom Massage 24 hours notice or they will be charge. No show/No calls will always be charged 100% of cost.

If a client is late for an appointment they may lose time from the original amount of time scheduled though they will owe the amount for the time scheduled.

Minors: If massage is being done on a minor, the signature below provides an understanding that “the signer” is responsible to make sure the minor feels safe. By law, absolutely no one under 18 will be massaged without a parent or guardian in the room. No action will be taken against Freedom Massage for treatment with this signature — all responsibility lies on the person whom signs.

Code of Ethics

Freedom Massage therapists are all licensed professionals. They all have the required hours
of schooling and training needed in the state of Pennsylvania. In order to keep their license
in good standing they each take continuing education classes and get more training here
at Freedom Massage. Our goal is to create a safe and professional environment for people
to experience the many benefits of our chosen craft.

1. Congratulations on your choice to practice self–care with massage therapy.

2. The answer is – YES! Try other massage therapists here! We support it! We encourage it! We
all have subtle strengths. We invite you to discover what you like about our ENTIRE TEAM.

3. Our therapists are excited to work with you at Freedom Massage. However, they will not
be in touch outside of Freedom Massage. We are unable to accept personal information,
give personal information, accept “Friend Requests” on Facebook, or any other form of
social media. It is suggested in our code of ethics for PA, and we follow those guidelines
here at Freedom Massage.

4. Out of respect for your privacy and keeping our professional boundaries, if a Freedom
Therapist sees you in public, they will not initiate contact. If you decide to initiate interaction,
please keep in mind that the therapist will likely keep conversation to a minimum.

5. All outside job opportunities for massage, chair massage, or anything related to self-care
should be passed on directly to our Owner. The direct line to our owner is on her business
card. All scheduling for our therapists is done in house only. If you need to email a therapist
you can do so at, just note their name in the subject.

6. The massage is all about YOU. Our therapists will not initiate conversation during session,
unless it is about pressure or YOUR comfort level. Of course they will respond if you initiate
conversation, though their answers may be brief as suggested in the PA code of ethics.

7. Please remember to let us know what areas you do not want worked on.

8. Please let us know what areas you would like us to focus on.

9. Please let the therapist know if you would like more, less, or the same pressure during
sessions. Your input is very valuable.

10. Let us know if you are too cold or warm. We can turn up the heated table or make

11. Each room has a white noise machine. Please let us know if you would like us to turn it
off before or during the session.

12. Please help us keep a quiet space upstairs. Please turn off your cellphone, speak
quietly, and be mindful when walking up stairs.

13. We want you to be 100 percent happy with your experience. Please feel free to call the
Owner directly with any feedback at 484-889-9749. Do not hesitate to contact her we want you to be 100% happy with your visit.

I understand Freedom Massage requires 24 hours for cancellations. If you understand this policy please type yes: *
Your answer
I have reviewed all the questions and answered them honestly. Please type yes if this is correct. *
Your answer
I will not hold Freedom Massage liable for any unforeseen health issues during or after my session. Please type yes if you agree: *
Your answer
I have reviewed the policies above and have provided the most up to date information on my health. I understand checking typing my name below works as my signature: (Required) *
Your answer
Thank you and enjoy ! Diane Matkowski, Owner of Freedom Massage
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