Massage Therapy Client Intake Form

I understand that the massage therapy that I am given is for the purpose of stress reduction, relief from muscular tension or spasm, and/or improving circulation. 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 therapy should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage  practitioners 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 given should be construed as such. Because massage therapy should not be performed under certain medical conditions, I affirm that I have stated all of 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. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.

I have read the above information. I have accurately answered the questions within the New Client Form, including all known allergies, medications, or products I am currently ingesting or using topically, and am over the age of 18 years old. I give permission to my Polished Technician to perform the treatment we have discussed and will hold him/her and his/ her staff harmless from any liability that may result from this treatment. I understand the procedure and accept the risks. I have chosen to proceed with the treatment after careful consideration of the possibility of both known and unknown risks, complications, and limitations. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I do not hold the Polished Technician, responsible for any of my conditions that were present, but not disclosed at the time of this procedure that may be affected by the treatment performed today.  I understand that this agreement will remain in effect for this procedure and all future procedures conducted by my Polished Technician.

A minimum of 24 hours notice is required to reschedule or cancel a booked appointment without penalty.

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As a courtesy, appointment reminders are sent out 48 hours prior to scheduled appointments either by text, email or both. If an appointment is cancelled or rescheduled within 24 hours of your appointment, you will be charged 50% of your service as a cancellation fee. If an appointment is cancelled or rescheduled within 4 hours of the appointment, or if you do not show up, you will be charged 100% of your service as a cancellation fee.
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If you, or another person in your household, has an infectious or contagious illness, please contact us as soon as possible to reschedule your appointment for a later date. For your safety and that of staff and other clients, please do not come to your appointment sick. A one-time allowance of last minute cancellation or reschedule will be permitted for sickness or family emergency. After that, the cancellation and no show policy will be in effect.

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Consent for Treatment -I understand that, because massage therapy 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 at this time, I voluntarily agree to assume those risks, and I release and hold harmless the practitioner/business from any claims related thereto. I give my consent to receive treatment from this practitioner.

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Signee Information

Health Information

By clicking 'I Agree' below, you agree that you have read and agree with the terms of the waiver and that the information you provided is accurate. You furthermore agree that your submission of this form, via the 'I Agree' button, shall constitute the execution of this document in exactly the same manner as if you had signed, by hand, a paper version of this agreement.