Intake Form _Workplace Massage

By checking this box I confirm that I do not have any of the following conditions which are contraindicate for massage:

• Fever/Acute Illness: Massaged circulation can worsen symptoms/spread infection.

• Contagious Disease: Skin infections (ringworm, impetigo) or systemic viruses (flu, COVID-19)

• Recent Blood Clots (DVT): Massage can dislodge a clot, leading to embolism.

• Uncontrolled Hypertension: high blood pressure that isn't managed by medication

• Heart conditions: increase venous return

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By checking this box, I confirm that I will disclose any of the following to my Massage Therapist before massage so areas can be avoided if need be to the following:

• Inflammation/Injuries: recent fractures, severe sprains, or acute swelling (wait 48-72 hours)

• Skin Issues: Open wounds, burns rashes, or severe varicose veins.

• Medical Implants: recent surgical sites, pacemakers, or artificial joints (work around them)
  

By checking this box, I willl provide to the Licenses Massage Therapist a healthcare provider signed "approval for massage" note if I have the following conditions:

• Cancer: massage is often beneficial, but pressure and technique must be modified for patients in active treatment.

• Pregnancy: Usually safe, but requires a trained therapist and specific positioning (side-lying) after first trimester.

• Blood Thinners: Clients on medications like Warfarin or Eliquis may bruise very easily.

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By checking this box, I confirm that the personal and medical information provided in this intake form is accurate to the best of my knowledge. *

By checking this box, I agree to inform the massage therapist of any changes in my health or medication BEFORE my session starts. *

By checking this box, I understand that massage therapist is intended to enhance relaxation, reduce pain and improve soft tissue function. I understand that massage therapy is not a substitute for medial examination, diagnosis, or treatment. I understand I should consult a physician for any physical or mental aliment I am aware of. *

By checking this box, I acknowledge that while massage is generally safe, there are some risks, including temporary muscle soreness, bruising, or lightheadedness. I understand that the massage therapist will use the information I provide to minimize these risks. *

By checking this box, I understand that for a workplace massage sessions, I will remain fully clothed. I understand that the suggested attire is form-fitting or athletic attire (such as spandex) to minimize fabric friction and ensure the best possible treatment experience.*

By checking this box, I understand that all personal, medical, and health related information shared with Revival of Hope Wellness is strictly confidential. Your "Protected Health Information" (PHI) includes your medical history, treatment notes, and contact details. My information will not be shared with, sold to, or discussed with any third consent unless legal circumstances by law is enforced. *

By checking this box, I understand that any illicit or suggestive remarks or advances made by the client will result in the immediate termination of the session, and I will be liable for full payment. *