Massage Intake Form
Haines Massage
First Name *
Last Name *
Street Address *
Town/City *
State *
Zip Code *
Phone number *
Date of Birth *
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Email Address
Would you like to receive newsletter via email?
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Referred by
May I thank them for referring you?
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The following information will be used to help plan safe and effective massage sessions. It will be kept confidential. Please answer to the best of your knowledge.
Have you had professional massage before?
Clear selection
Do you have an allergies or skin sensitivities to oils or lotions? *
If so, please explain
Do you sit for long hours at a workstation, computer or driving?
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Do you have any particular goals for this massage session?
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If so, please explain
Are you currently taking any medications, prescription or over-the-counter? *
If so, please explain
Please select any condition below that applies to you *
Required
Please explain any condition you checked above
Is there anything else about your health history that you think would be useful for your massage therapist to know?
Consent for Treatment
Client Responsibilities
If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician or other qualified medical specialist for any mental or physical ailment of which I am aware.

Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so.
Understanding all of this, I give my consent to receive care, by typing my name below. *
Acknowledgement of cancellation policy
Cancellations and Reschedules
If you need to cancel or reschedule, please do so at least 24 hours before the start of the appointment time to avoid a charge of 50% of the scheduled appointment price. Should I need to apply the cancellation policy, you will be invoiced via email and this amount must be paid before your next scheduled appointment.

I will waive the fee in cases of illness or inclement weather.

No-shows
Should you forget or consciously choose to miss your appointment you will be charged 50% of the scheduled appointment price. You will be invoiced via email and this amount must be paid prior to your next scheduled appointment.

Late Arrivals
If you arrive late, your session may be shortened. You will be charged the full amount of the scheduled session.

Client initials *
COVID-19 Waiver
I understand that preventative measures and intensified sanitation protocols intended to reduce the spread of COVID-19 have been implemented. However, because this work involves close physical proximity over an extended period of time in a closed space, there may be an elevated risk of disease transmission, including COVID-19.

I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this treatment and give my express permission to Haines Massage to proceed with providing care.
Understanding all of this, I give my consent to receive care, by typing my name below. *
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