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Massage Therapy Form .𖥔 ݁ ˖༄

Introduce Yourself

Contact Information

Emergency Contact

Communication & Boundaries

Your comfort, safety, and consent are my priority. Is there anything that would help you feel more comfortable during your session, such as sensory preferences, communication preferences, or touch boundaries? You may request adjustments or withdraw consent at any time.

Medical History

Do you have any allergies, injuries, chronic pain, or diagnoses that you'd like me to consider during your treatment?

Pregnancy Status (if applicable)

Current Health Support(s)

Are you taking any medications that may affect today's massage (such as blood thinners, pain medication, or steroids)?

What is your intention?

Thank you for completing this intake form. Once your form has been submitted & your appointment request accepted, you will be contacted with further details to finalize your booking! <3

I agree to be part of the newsletter?

Confidentiality & Client Agreement

All information provided in this intake form and shared during your session will be kept strictly confidential and is collected solely to ensure that your care is safe, appropriate, and personalized to your needs. By signing below, you confirm that:

༄ The information you have provided is complete and accurate to the best of your knowledge. ༄ You understand the nature, benefits, and potential risks of massage therapy and voluntarily consent to receive treatment. ༄ You accept responsibility for informing your therapist of any changes in your health, medications, injuries, or medical conditions that may affect your treatment.

Both the client and the therapist agree to respect the confidentiality of all personal information and discussions that take place before, during, and after the session, except where disclosure is required by law.

Private Studio Policy

Massage therapy sessions are provided in a private studio. To protect the privacy, safety, and security of the practice, you agree not to share, publish, distribute, or disclose the studio address or any identifying location details with any third party without the therapist's prior written consent.

Only the scheduled client may attend the appointment. Guests, companions, and additional visitors are not permitted unless prior arrangements have been made and approved by the therapist.

Liability Waiver

I understand that massage therapy is a therapeutic treatment intended to support my health and well-being and that no specific results can be guaranteed. I have disclosed all relevant health information and agree to inform my therapist of any changes to my condition.

By signing below, I voluntarily consent to treatment and accept responsibility for my participation. I release the therapist from liability for any injury or adverse reaction resulting from incomplete or inaccurate health information that I have provided, except where otherwise required by law.

Deposit, Cancellation & Rescheduling Policy
Deposit: To secure your appointment, please send a $15 deposit via etransfer (this will be deducted from your total balance).
48-Hour Grace Period: You may cancel within 48 hours of booking for a full refund.
Late Cancellations: Cancellations made after this 48-hour window are strictly non-refundable.
Conduct & Termination
Professional boundaries must be maintained at all times. Should I engage in any form of misconduct or inappropriate behaviour, the therapist reserves the right to terminate the session immediately. In such an event, no refund will be provided.
IMPORTANT NOTE: I am currently not issuing insurance receipts for massage treatments.
Signature