Client Information

Full Name *

Date of birth *

Gender *

Address

Street Address

City

Postal code

Phone Number *

Email Address *

Emergency Contact Name *

Emergency Contact Phone *

Medical History

Please check any of the following conditions you have or had: *

Yes

No

If yes, please explain: *

Allergies to oils, lotions, or scents (please specify ): *

Do you have any recent injuries or areas of pain or discomfort? *

Yes

No

If yes, please describe: *

Massage Goals and Preferences

Are there any specific areas you would like the therapist to focus on or avoid? *

Focus areas:
Avoid areas:

Preferred pressure level: *

Light

Medium

Firm

Risks, Comfort, and Professional Conduct

Please read and initial each statement for Massage therapy : *

I understand that massage therapy is not a substitute for medical examination or diagnosis.

I acknowledge that massage may cause temporary soreness, redness, or sensitivity.

I will communicate with the therapist regarding my comfort and any adjustments needed.

I understand that any inappropriate behavior will result in immediate termination of the session.

I will notify the therapist of any changes in my medical condition or medication prior to future sessions.

I consent to therapeutic massage and understand I may withdraw consent at any time.

Client Declaration and Consent

Check all boxes for Massage Therapy : *

I confirm the information provided is accurate and complete.

I understand the nature of massage therapy and its potential benefits and limitations.

I have had the opportunity to ask questions and voluntarily consent to receive massage treatment at Idens Laser Clinic.

By signing below, I confirm that I have read and understood the information provided and consent to proceed with the treatment.

Client Signature: *

Clear

Date: *

Practitioner Name (Print): *

Practitioner Signature: *

Clear

Date: *

I agree to terms & conditions provided by the company.

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