Digital Intake Form

Digital Intake Form

Complete Your Intake, Enhance Your Experience: Your Wellness Journey Starts Here!

It is necessary to fill out the intake form before starting the massage treatment. To streamline the process, it is best to complete the form before your appointment. Completing the form during the appointment takes away from the time allocated for the treatment.

Massage

The following information will be used to help plan safe and effective massage sessions. It will be kept confidential. Please answer to the best of your knowledge.

Personal Information
*State:
*Date of Birthday
Massage Notes
Health Information
LIABILITY DISCLAIMER STATEMENT
By signing this form or proceeding with services, I acknowledge and agree to the following terms:
1. I give my voluntary consent to receive massage therapy services.
2. I understand that therapeutic massage is not a substitute for professional medical care, diagnosis, or treatment, and it is not intended to replace medications or medical supervision.
3. I acknowledge that the massage therapist does not diagnose medical conditions or prescribe medications.
4. I confirm that I have received clearance from my physician, if necessary, to receive massage therapy.
5. I understand that while massage therapy has many benefits, there are potential risks involved, which may include but are not limited to: superficial bruising, short-term muscle soreness, or the aggravation of previously undiscovered conditions. I hereby release Kneads Massage and its therapists from any and all liability related to such risks or any injury that may occur during or following the session.
6. I acknowledge the importance of informing my massage therapist of any existing medical conditions, injuries, allergies, or medications I am taking. I also understand the need to update the therapist regarding any changes to my health status to help ensure a safe and effective session.
7. I understand that it is my responsibility to communicate any discomfort, pain, or concerns during the massage session so the therapist can adjust techniques as needed.
8. I acknowledge that both I and the massage therapist reserve the right to terminate the session at any time for any reason.
9. I have had the opportunity to ask questions about the massage therapy process, and all of my questions have been answered to my satisfaction.
10. Kneads Massage shall not be held liable for any loss, theft, or damage to personal property, including but not limited to clothing, electronics, jewelry, or other valuables, that are brought onto the premises or inadvertently left behind. Clients are seen in succession, and while reasonable care is taken to maintain a safe and respectful environment, it remains the sole responsibility of each client to safeguard their belongings at all times.

Skincare

The following information will be used to help plan safe and effective massage sessions. It will be kept confidential. Please answer to the best of your knowledge.

Personal Information
Health Information
Skin Care History
LIABILITY DISCLAIMER STATEMENT
By signing this form or proceeding with facial treatment services, I acknowledge and agree to the following terms:
1. I give my voluntary consent to receive facial treatments provided by Kneads Massage.
2. I understand that facial treatments are not a substitute for professional medical care, dermatological diagnosis, or prescribed medications.
3. I understand that the esthetician or practitioner does not diagnose medical conditions or prescribe medications, and that any advice given is for skincare purposes only.
4. I confirm that I have disclosed all known allergies, skin sensitivities, medical conditions, and medications (including topical treatments such as Retin-A, Accutane, or other exfoliants) that may affect my skin's response to treatment. I understand that failure to do so may increase the risk of an adverse reaction.
5. I understand that possible side effects of facial treatments may include, but are not limited to: redness, irritation, peeling, breakout, discomfort, sensitivity, or allergic reaction. I acknowledge these risks and release Kneads Massage and its practitioners from any liability related to these or other reactions that may occur during or after the treatment.
6. I understand that results vary depending on skin type, condition, and adherence to post-treatment care. No guarantees have been made regarding outcomes.
7. I agree to follow all pre- and post-treatment instructions provided to me to ensure the best results and minimize the risk of complications.
8. I understand that either I or the practitioner may discontinue the treatment at any time if necessary.
9. I have had the opportunity to ask questions regarding the facial treatment process, and all questions have been answered to my satisfaction.
10. Kneads Massage shall not be held liable for any loss, theft, or damage to personal property, including but not limited to clothing, electronics, jewelry, or other valuables, that are brought onto the premises or inadvertently left behind. Clients are seen in succession, and while reasonable care is taken to maintain a safe and respectful environment, it remains the sole responsibility of each client to safeguard their belongings at all times.