Forms

Below, you will find the intake forms for your upcoming appointment at Unleashed Relief.

Please note: if you have booked your appointment either online or over the phone, and an email address is on file, an intake form will be automatically emailed to you. If this happens, please use the link in the email so that your intake form can be processed quicker. Thank you for your cooperation!

Click to print Unleashed Relief Client Intake Form

To take Form with you Print above form, Complete it, and bring to your first visit.

Otherwise Complete the Three Forms below to Submit online.

Step 1 Personal Information

All fields marked with an asterisk are required

Name*

Email*

Daytime Phone*

Evening Phone*

Your Mailing Address*

City*

State*

Zip*

Date of Birth MM/DD/YYYY*

Occupation (Optional)

Employer (Optional)

Primary Physician*

Emergency Contact Name*

Relationship to you*

Phone Number*

How did you hear about us?

Medical Information

Are you taking any medications?

If yes, please list name and use:

Are you currently pregnant?

If yes, how far along?

Any high risk factors?

Do you suffer from chronic pain?

If yes, please explain

What makes your pain better?

What makes it worse?

Have you had any orthopedic injuries?

If yes, please list:

Explain any conditions you have marked above

Massage Information

Have you had a professional massage before?

What type of massage are you seeking?

Relaxation Therapeutic/deep tissue Other

If other, please explain:

What pressure do you prefer?

Do you have any allergies or sensitivities?

If yes, please explain.

Are there any areas (feet, face, abdomen, etc.) you do not want massaged?

If yes, please list

What are your goals for this treatment session?

Please list any areas of discomfort. (Please be specific)

Type Your Name

Date

By checking this box, 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.

2 + 4 = ?

Step 2 Complete Massage Client Information & Informed Consent Form

Massage Client Information & Informed Consent Form

I understand that massage body workers and holistic practitioners are not medical doctors and do not diagnose illness, disease, or any physical or mental disorder. I acknowledge that massage and alternative holistic therapies are not substitutes for medical treatment, and that Unleashed Relief, the company, recommends I see a primary healthcare provider for service. I understand that is my responsibility to communicate with my therapist if I have concerns or questions about my session. I do not have any injuries or conditions that would prevent me from receiving a massage, nor have I been told by a health care provider that I should not receive massages or alternative therapies.

I understand that massage therapy and body work services are a therapeutic health aid and are non-sexual. I understand my massage therapist reserves the right to end a therapy session in case of sexual innuendos or advances from the client. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the massage, and I will be liable for full payment of the scheduled session.

Any information exchanged during a massage or body work session is confidential and is only used to provide me with the best health care services available. I understand that a massage therapist will ask me questions about my health and physical condition and that I am obligated to answer truthfully and honestly about my health history in full detail.

I understand that my feedback is essential in my treatment, and that if I experience any unusual discomfort and/or pain during my massage session, it is my responsibility to inform the therapist in order to enable the therapist to adjust the pressure or technique being used.

The therapist reserves the right to decline, discontinue, or restrict services based on any provided information that may indicate that massage therapy would put my health or the therapist’s health at risk. I understand that massage therapy and body work services are a therapeutic health aid and are non-sexual. I understand my massage therapist reserves the right to end a therapy session in case of sexual innuendos or advances from the client. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the massage, and I will be liable for full payment of the scheduled session

I acknowledge that I am responsible to be on time for my appointments and that the therapist is not under any obligation to extend my therapy session. I also agree that I am responsible to pay for the full time I have booked with the therapist if I am late. I understand that my appointment time is reserved for me only. If I miss an appointment or am unable to give twenty-four (24) hours’ notice when I need to change or cancel my appointment, I agree to pay the company in full for the booked appointment time. I further understand that I will be additionally charged $35.00 for any returned checks.

I understand that massage therapy and body work are for the purposes of stress reduction, relief from muscular tension and spasm, general relaxation and improvement of circulation and energy flow.

I understand that the practitioner does not prescribe medical treatment of pharmaceuticals, nor does he perform any spinal manipulations.

I understand that service offered today, and in the future, are not a substitute for medical care and that any information provided to me by the therapist is purely for educational purposes and is not diagnostically prescriptive in nature.

I have stated all of my known medical conditions on the Client Intake form. I have consulted a medical doctor or licensed medical health care practitioner regarding any checked or described conditions.

I understand that it is solely my responsibility to keep the therapist updated on any changes in my physical health and I further understand that the company and the therapist shall not be liable for any purpose and for any reason whatsoever, should I fail to do the needful as per this paragraph

I have reviewed this form in its entirety and I have discussed all my concerns regarding my treatment with my therapist

Name

Date

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Phone

Email Address

Required if Minor

Step 3 Policy Notification Form

Policy Notification

We appreciate that you’ve chosen us for your massage and bodywork needs. To provide the best service possible to our clients we have implemented the following policies.

Cancellation Policy - - - We respectfully ask that you provide us with a 24 hour notice of any scheduled changes or cancellations. We understand that certain circumstances may cause you to need to cancel or reschedule your appointment, but please give the very minimum notice of 3 hours. This allows us to offer that time to another client. Any appointments cancelled without at least a 3 hour notice are subject to $30.00 cancellation fee. Any missed appointments without notification will result in a charge for the full fee for the treatment missed which will be collected at the time of your next appointment. Your cooperation and consideration are appreciated

Late Arrival Policy - - - We request that you arrive 5-10 minutes prior to your appointment time to allow time to fill out any required paperwork as well as answer any intake questions your therapist may have. WE understand that issues can arise that may cause you to be late for your appointment. However, we ask We respectfully ask that you provide us with a 24 hour notice of any scheduled changes or cancellations. We understand that certain circumstances may cause you to need to cancel or reschedule your appointment, but please give the very minimum notice of 3 hours. This allows us to offer that time to another client. Any appointments cancelled without at least a 3 hour notice are subject to $30.00 cancellation fee. Any missed appointments without notification will result in a charge for the full fee for the treatment missed which will be collected at the time of your next appointment. Your cooperation and consideration are appreciated.that you call to inform us if this ever occurs so we can do our best to accommodate you. Appointment times are reserved for each client, so oftentimes we cannot exceed that reserved time without making the next client late. For this reason, arriving after your appointment time may result in loss of time from your massage so that your session ends at the scheduled time. Full service fees will be charged even when sessions are shortened due to late arrival. In return we will do our best to be on time, and if we are unable to do so we will add time to your session to make up for our late arrival or adjust the service charge accordingly.

Inappropriate Behavior Policy - - - 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 your session and a refusal of any and all services in the future. You will be charged the full service fee regardless of the length of your session. Depending on the behavior exhibited we may also file a report with the local authorities if necessary. Treat your therapist with respect and dignity and you will be treated the same in return.

Financial Responsibility - - - I understand and agree that I am financially responsible for all services. I understand that all fees are payable at the time that services are rendered.

Cancellation Policy - - - I understand that I am asked to provide a minimum of a 3 hour notice if I need to cancel/reschedule my appointment , and that I may be charged a $30 fee if I do not give sufficient notice. I understand that I will be charged the full fee for treatment scheduled if I miss my appointment without giving Financial Responsibility I understand and agree that I am financially responsible for all services. I understand that all fees are payable at the time that services are rendered.

Privacy Policy Acknowledgement - - - I acknowledge that Unleashed Relief, “Notice of Privacy Policy” has been provided to me. I understand I have a right to review Unleashed Relief’s Notice of Privacy Policy prior to signing this document. The notice of Privacy Policy describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of bills or in the performance of Unleashed Relief. The Notice of Privacy Policy for Unleashed Relief is provided upon request. This Notice of Privacy Policy also describes my rights and Unleashed Relief’s duties with respect to my protected health information. Unleashed Relief reserves the right to change the privacy practices that are described in the Notice of Privacy Policy. I may obtain a revised notice of privacy policy by requesting a copy be sent to me by email or asking for one at the time of my next appointment.

Name

UnleashedRelief.com

Massage Therapist Council Bluffs

Forms

Forms

Below, you will find the intake forms for your upcoming appointment at Unleashed Relief.

Please note: if you have booked your appointment either online or over the phone, and an email address is on file, an intake form will be automatically emailed to you. If this happens, please use the link in the email so that your intake form can be processed quicker. Thank you for your cooperation!

To take Form with you Print above form, Complete it, and bring to your first visit.

Otherwise Complete the Three Forms below to Submit online.

Step 1 Personal Information

All fields marked with an asterisk are required

Medical Information

Massage Information

Step 2 Complete Massage Client Information & Informed Consent Form

Required if Minor

Step 3 Policy Notification Form