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A New Truly
About Truly Bodywork, Inc.
About Your Massage Therapist
Why the Change?
Cancellation Policy
Massage and Bodywork Services
Rehabilitative Massage Therapy
Sports Massage Therapy
Cupping Therapy Massage
Reflexology
AromaTouch Technique
Essential Oil Sports Massage
IASTM
Times and Location
1001 Sneath Ln, Suite 105
Client Intake Form
Please fill out to the best of your ability. This form is for informative use only, for only your massage therapist to see.
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Indicates required field
Name
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First
Last
Phone Number
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What Massage Pressure do you Prefer?
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Light
Medium
Firm
Deep
Address
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Line 1
Line 2
City
State
Zip Code
Country
Email
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Date of Birth
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Date of Last Massage
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How Did You Hear About Truly Bodywork? (Referral?)
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List Regular Exercise/Sports & Frequency
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Medications Currently Taking
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The following information will be used to help plan safe and effective massage sessions. Please answer the questions to the best of your knowledge.
Do you have difficulty lying on your front, back, or side?
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Yes
No
If yes, please explain
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Do you have allergies to oils, lotions, or essential oils?
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Yes
No
If yes, please explain
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Do you have sensitive skin?
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Yes
No
If yes, please explain
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Are you wearing
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Contact Lenses
Dentures
Hearing Aids
None
Do you sit long hours at a work, computer, or driving?
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Yes
No
If yes, please explain
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Do you perform any repetitive movement in your work, sports, or hobby?
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Yes
No
If yes, please explain
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Do you experience stress in your work, family, or other aspect of your life?
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Yes
No
If yes, how do you think it has affected your health?
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Is there a particular area of the body where you are feeling tension, stiffness, pain or other discomfort?
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Yes
No
If yes, please identify
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Do you have any particular goals in mind for this massage session?
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Are you currently under medical supervision or seeing a Chiropractor?
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Draping will be used during the session – only the area being worked on will be uncovered. Clients under the age of 17 must be accompanied by a parent or legal guardian during the entire session. Informed written consent must be provided by parent or legal guardian for any client under the age of 17.
I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the therapist 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, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of. 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 given 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, and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so.
Client Behavior - 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.
Cancellation Policy - To avoid being charged for a late cancellation or no-show, I will let Truly Bodywork know 24 hrs hours prior to my appointment time if I will be unable to make my scheduled appointment. I will give a minimum of 24 hour notice BY EMAIL for any cancellations or rescheduling. However, if I do not give at least 24 hour notice of your cancellation, I agree to allow Truly Bodywork to charge the card on file.
No Call/No Show - I agree that should unexpected circumstances occur and I am unable to attend my scheduled appointment, that I will notify Truly Bodywork by close of that business day BY EMAIL. If no contact is made, Truly Bodywork will deem the service a "No Call / No Show". In the event of a "No Call / No Show", I agree to allow Truly Bodywork to charge the card on file 100% of the full cost of my session, or the forfeiture of a gift certificate. I understand that this is to ensure that in the event of a late cancellation or no-show, Truly Bodywork will be able to collect the fees associated with Truly Bodywork’s cancellation policy.
- If I am late to my session, Truly Bodywork will do their best to accommodate the time remaining of my scheduled appointment without penalizing the following client.
Email Policy – I understand that Truly Bodywork will use my email address for appointment reminders, promotions, and news from Truly Bodywork only. Truly Bodywork understands that privacy is very important and will not sell, rent, or give client information out.
Privacy Policy – All Client information is held strictly confidential except where required by law.
Understanding all of this, I give my consent to receive care.
Please Type Your Name Here to hold place for your signature when you come in for your appointment.
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