Essera Spa Intake
New Massage Client Intake Form
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Name_____________________________________________ Email______________________________________________ Phone_________________________________________________________________  Emergency Contact ______________________________________  DOB__________________________________________________  Occupation_______________________________________________________________  ● Have you had a professional massage before? Yes No                                             ● Do you have sensitive skin or allergies to oils, lotions or scents? Yes No ___________________________________________________________                               ● In what areas are you experiencing tension, pain or other discomfort?__________________________________________________________________                   ● Do you have specific goals in mind for this massage? Yes No _________________________________________________________________                     ● Are you pregnant? Yes No                  ● Are you currently under medical supervision or taking any medications? Yes No ___________________________________________________________________                ● Is there anything else about your health history the therapist should know? ___________________________________________________________________ *
Please check any condition listed below that applies to you:contagious skin condition__ open sores or wounds__ osteoporosis__ TMJ__deep vein thrombosis/blood clots__ easy bruising__ rheumatoid fibromyalgia__ cancer__arthritis/osteoarthritis/tendonitis__ recent accident__ recent surgery__ epilepsy__ artificial joint__ headaches/migraines__ heart condition__ diabetes__ sprain/strain__ back/neck problems__ high/low blood pressure__ circulatory disorder__ *
I, ___________________________ understand that massage is provided for the purpose of relaxation & relief of muscular tension. If I experience pain or discomfort during this session, I will immediately inform the therapist. I understand that massage does not substitute for medical examination, diagnosis, or treatment, and that I should see physician or qualified medical specialist for any mental or physical ailment. 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 should be construed as such. Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions. I agree to keep the therapist updated as to changes in my medical profile and understand that there will be no liability on the therapist’s part should I fail to do so. Any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session. The Licensed Massage Therapist reserves the right to refuse massage services to anyone who has a condition for which massage is contraindicated.Professional draping will be used during the session. Informed written consent must be provided by parent or legal guardian for any client under the age 17. *
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