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Client Intake Form

Personal Information
Medical Information
Are you taking any medication?
Are you currently pregnant?
Do you suffer from chronic pain?
Have you had any orthopedic injuries or surgeries?
Massage Information
Have you had a professional massage before?
What type of massage are you seeking?
What pressure do you prefer?
Do you have any allergies or sensitivies?
Are there any areas (feet, face, abdomen, etc) you do not want massaged?
Please indicate any of the following that apply to you
Are you right or lefthanded?
Please select the areas you would like to focus on in this session:
I understand that massage is not a replacement for medical care and that no medical diagnosis will be made. Because massage and bodywork therapy may be contraindicated due to certain medical conditions, I affirm that I have informed the therapist of all known medical conditions and will keep the therapist updated as to any changes in my medical condition going forward. If I experience any pain or discomfort during the session, I will immediately inform the therapist so that the pressure and/or manipulations, draping or environment may be adjusted to my level of comfort.
CANCELLATION POLICY - Should I cancel or miss an appointment with less than 12 hours notice, I authorize Rooted Fire Wellness LLC to charge my VISA/MC/Amex/Discover Card or checking account for the 50% of the session fee.
LATE POLICY - I will arrive to my appointment on time or 5-10 min earlier. If I am running late, I will call or text to let the therapist know. I acknowledge that I am only guaranteed my scheduled time. The therapist is not obligated to give me the full session if it is my fault I am late.
INAPPROPRIATE BEHAVIOR POLICY - I understand that massage therapy is for relaxation and therapeutic purposes only. There is absolutely no sexual component to massage whatsoever. Any insinuation, joke, gesture, conversation, or request otherwise will result in immediate termination of my session and a refusal of any and all services in the future. I understand that I will be charged the full service fee regardless of the length of my session. I understand that depending on the inappropriate behavior exhibited a report may be filed with the local authorities if necessary. I will treat the therapist with respect and dignity and in return I will be treated the same.

By signing below, you agree to the following:

I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time.

I hereby voluntarily release Rooted Fire Wellness LLC and therapist from any liability should my condition be aggravated at any time. By printing my name below, I agree that I have read the information above and have decided to receive a massage. *

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