Name

First Name

Last Name

Date of Birth

YYYY

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

General Information

Have you received massage therapy before?

Yes

Do you have any allergies?

Yes

Option 3

Have you ever received cupping therapy?

Yes

Are you interested in aromatherapy or use of essential oils during your treatments?

Yes

Have you experienced any recent surgery, accident or injury?

Yes

Option 3

Are you pregnant?

Yes

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What to Expect

After a short consultation, your massage therapist will step out of the treatment room to allow you to prepare for massage. You will most likely be asked to undress and then lay on the treatment table under the sheet. The sheet is there to preserve modesty and will be used throughout the entire massage.

Cupping

Cupping involves the use of “cups” that allow the therapist to manipulate soft tissue in a unique way. Most massage techniques involved applying pressure throughout the areas of concern in order to stimulate circulation, break up adhesions, release muscular tension and reduce pain. However, cupping provides all of these benefits by lifting the tissues upwards.

Note

One of the immediate responses to any massage treatment is the increase in systemic circulation. Cupping may result in redness or markings upon the skin that last for several days. This is the result of increased circulation and is neither painful nor harmful.

I have read and understand the love statement

Post Treatment Care

After receiving a massage it is important to stay hydrated. Most people should measure their daily water intake by dividing their body weight in half and then drinking that number of ounces of water, (if I weight 200 pounds then I should drink 100 fluid ounces of water per day).

Service Rates

Payment is due immediately following appointments. Clinic self pay rates are as follow: Massage Therapy 30 minute session: $45 60 minute session: $80 90 minute session: $115 Paraffin Wax Hands: $15 Feet: $15 Hands and Feet: $25 Infrared Sauna 15 minute session: $15 30 minute session $30 Whole Body Vibration Therapy (WBVT) 5 minute session: $5 10 minute session: $10 Month unlimited: $50

Cancelation Policy

A $30 fee will be applied to appointments canceled with less than 24 hours notice.

Agree & Sign

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 my session, I will immediately inform the therapist so that the pressure and/or technique 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 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 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.

I understand & agree

Effleurage Massage Therapy

Effleurage Massage Therapy