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A New Truly
About Truly Bodywork, Inc.
About Your Massage Therapist
Cancellation Policy
Massage and Bodywork Services
Rehabilitative Sports / Deep Tissue Massage Therapy
Cupping Therapy Massage
IASTM
Times and Location
901 Sneath Ln, Suite 115
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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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
(Please Click on Drop Down Menu and Choose your Preference)
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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I agree to read the following and upon agreement, I will type my name in the signature box to hold my place for my appointment.
Draping will be used during the session – only the area being worked on will be uncovered. When applicable, 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.
Tardiness - I understand that appointment times are as scheduled and cannot extend beyond the stated time to accommodate late arrivals. I agree to be on time for my appointment. 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.
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 am unable to make my scheduled appointment. I understand that I am responsible for paying the missed appointment/late cancellation fees.
Financial Responsibility - I understand that my electronic signature below confirms your financial responsibility for all services rendered.
Release of Medical Records - My signature below authorizes the release of all of my medical records on file in this office, for the purpose of processing my claims, to the following: your attorney, the healthcare providers attending to this condition, and the insurance case managers. Medical records will not be edited unless otherwise stated in an exclusive release of medical records signed through my attorney.
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.
I understand that if I need to reschedule for whatever reason,
(especially if I am not feeling well)
, I will contact Truly Bodywork via email at
[email protected]
or via text at 650.636.6327 as soon as possible to reschedule.
I understand that the only form of communication with Truly Bodywork is through email or text.
Sickness - Massage/bodywork is not appropriate care for infectious or contagious illness. I will cancel my appointment as soon as I am aware of that I may have an infectious or contagious condition. I understand that if the cancelation is within the 24-hour notice period, the cancellation fee may be waived.
However, if I do not give at least 24 hour notice of my cancellation, I agree to allow Truly Bodywork to charge the card on file. Amid the ongoing uncertainty of COVID-19, I am aware that Truly Bodywork has modified their cancellation policy to offer greater flexibility to all their clients.
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 or TEXT
. 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.
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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