Reiki Massage Therapy Intake Form

Date

Client Contact Information

First name

Last name

Phone

Country/Region

Address

City

Zip / Postal code

Emergency Contact

First and Last Name

Phone

Questionnaire

How did you hear about Anchored Soul Therapy?

Have you had a massage before?

yes

Have you had a reiki before?

yes

When was your last massage / reiki session?

Do you exercise or play sports?

yes

Client Medical History

Birthday

If marked yes to anything above, please explain below

Are you currently taking any medication?

yes

If answered yes above, please explain more here.

Policies & Procedures

Cancellation Policy

We understand that life can be unpredictable, and plans may change. In order to provide the best service to all of our clients and honor the time set aside for your session, we kindly ask that you adhere to the following cancellation policy:

Cancellation Notice: If you need to cancel or reschedule your appointment, please provide at least 24 hours' notice prior to your scheduled time.
Late Cancellations: Cancellations made within less than 24 hours of the scheduled appointment will incur a cancellation fee of 50% of the total service cost. This fee will be charged to the card on file or must be paid before rescheduling.
No Shows: Failure to show up for an appointment without prior notice will result in a charge of 100% of the total service cost. No further appointments can be scheduled until this fee is paid.
Emergency Exceptions: We understand that emergencies happen. If you experience an unexpected situation that requires last-minute cancellation, please reach out to us as soon as possible, and we will handle it on a case-by-case basis.

By booking an appointment, you agree to adhere to this cancellation policy. Thank you for understanding and supporting the smooth operation of our practice.

By checking this box, I acknowledge that I have read, understood, and agreed to the terms outlined above.

Massage Therapy Service Agreement

By booking your session, you acknowledge and agree to the following terms regarding the massage therapy services provided:

Therapeutic Services Only: I understand that the massage therapy services provided are intended solely for therapeutic and relaxation purposes. These services are not a substitute for medical treatment or diagnosis and should not be interpreted as such. The massage therapist does not diagnose, prescribe, or treat medical conditions, illnesses, or injuries.
Medical Advice: I acknowledge that it is my responsibility to seek professional medical advice from a licensed healthcare provider for any medical concerns or conditions that I may have. The massage therapist will not recommend or prescribe medications or medical treatments.
Communication of Medical Conditions: I agree to fully inform the therapist of any known medical conditions, injuries, or changes in my health status prior to the session. I understand that failure to disclose this information may affect the safety and effectiveness of the session.
Changes in Medical History: I agree to notify the therapist immediately of any changes in my medical history or physical condition that may impact my ability to receive massage therapy. This includes but is not limited to new diagnoses, surgeries, injuries, or medications.
Client Responsibility: I understand that I am responsible for communicating any discomfort or concerns during the session and that I may request a modification or discontinuation of the treatment at any time.

By checking this box, I acknowledge that I have read, understood, and agreed to the terms outlined above.

Cupping Therapy Waiver and Consent

Cupping therapy, also known as vacuum therapy, is an ancient therapeutic practice that involves placing cups on the skin to create suction. This technique is used to promote blood circulation, relieve muscle tension, reduce inflammation, and facilitate natural healing within the body. Cupping may also help alleviate pain, boost immunity, and improve overall well-being.

Please Note: While cupping therapy has many benefits, it is not a substitute for professional medical treatment or diagnosis. Always consult with a licensed healthcare provider for any medical concerns.

Possible Marks/Discoloration Cupping therapy may result in temporary marks or discoloration on the skin. These marks, often referred to as "cupping marks," are caused by blood being drawn to the surface and typically fade within a few days to a week. These marks are not bruises and do not indicate harm to the body.

Client Responsibilities

Medical Conditions and Medications: I agree to fully inform the therapist of any and all medical conditions, injuries, or medications that may affect my ability to safely receive cupping therapy. This includes, but is not limited to, cardiovascular issues, blood disorders, skin conditions, pregnancy, or recent surgeries.
Communication of Changes: I understand that it is my responsibility to notify the therapist of any changes in my medical history or current health status prior to each session.

By checking this box, I acknowledge that:

I have informed the therapist of any medical conditions, injuries, or medications that may affect my ability to safely receive cupping therapy.
I understand the potential effects, including temporary marks, and consent to the service.
I waive any liability and hold the therapist harmless for any injury or discomfort resulting from cupping therapy.

Inappropriate Behavior Policy

Our practice is committed to providing a safe, respectful, and professional environment for both clients and staff. Any inappropriate behavior, including but not limited to sexual advances, suggestive comments, or inappropriate touching, will not be tolerated. If such behavior occurs, the session will be terminated immediately, and the client may be refused future services. We prioritize maintaining a space of trust, comfort, and professionalism, and expect all clients to uphold these standards during their sessions.

By checking this box, I acknowledge that I have read, understood, and agreed to the terms outlined above.