Massage Therapy Consultation Form

Personal Information

Name

Birthday

Address

Phone

Email

Emergency Contact

Medical History

Do you have any of the following conditions?

Check all that apply

Do you have any other medical issues not listed above?

Have you had any recent medical procedures (within last 6 months), including plastic surgery?

Are you currently pregnant?

Yes

No

Are you allergic to any oils, lotions, or creams?

Yes

No

Is your skin easily irritated or sensitive?

Yes

No

Do you find it difficult to lie down on your stomach, back, or side?

Yes

No

Let's customize your massage experience

Have you ever had a professional massage?

Yes

No

What level of pressure do you prefer for massage?

Light

Medium

Deep

Which specific area(s) would you like me to concentrate on during this massage?

Which area(s) do you prefer not to have massaged?

Please check the box(es) that best describe your reasons for seeking massage therapy:

Stress relief and relaxation

I have specific areas of pain or discomfort.

I am an athlete and need help with muscle recovery.

I want to improve blood circulation and overall health.

Injury or post-operative recovery

Is there anything else you'd like me to know?

For your health and safety

At Gin Wellness, massage therapy procedures are performed with the proper technique, products, and instruments, and with your safety in mind. However, there still are some risks associated with massage therapy. This consent form is intended to inform you of the risks of the procedure and to obtain your informed consent for the procedure.

Please click the check boxes below to agree to each statement.

I understand that an allergic or adverse reaction to the massage therapy and/or massage lotions can occur. The symptoms can include, but not limited to, redness, swelling, soreness or tenderness, bruising, and short term muscle ache. I understand the effects may be worse for people with sensitive skin or skin conditions.

If symptom persists, I agree to seek medical attention at my own expense.

If I experience any pain or discomfort, I will inform the therapist to have the pressure or techniques adjusted to my comfort level.

I have provided accurate information regarding my health history and agree to keep the therapist and salon informed of new diagnoses.

I understand that I may choose to leave on as much clothing as I would like, and am able to stop the massage at any time.

I understand that the massage therapy provided is for therapeutic purposes only. It is designed with the primary goal of promoting overall health, well-being, and relaxation.

I completed the above form to the best of my knowledge. I have had the opportunity to ask any questions and have received satisfactory answers. I will inform the therapist of any changes to the above information. I am over the age of 18 and consent to the procedure. If I am under the age of 18, my parent/guardian must sign below. I will not hold the therapist, spa, or employees liable for any injury or damage that may occur as a result of the massage therapy or for any issues not disclosed at the time of my service.

Signature

Date