CLIENT INTAKE FORM

Information Agreement

CONTACT INFORMATION
To Be Completed By Client
Name Mobile Phone Number OK to leave
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I would like to receive Text Notifications (Messaging & Data Rates may apply; Please list service provider):
Address City/State Zip

Email Address Date of Birth

Emergency Contact Name & Phone Number

ELEMENTS MASSAGE® POLICIES

Please review and check each box. (Please ask us if you have any questions, concerns or need additional information):

I may undress to my comfort level. I will be properly draped, meaning covered by the sheet and/or blanket at all times. The therapist will only uncover the part of the body
that is being worked on during the massage session.
As further explained below, the therapist reserves the right to terminate the session at any time in the event of any sort of inappropriate behavior from me.
Elements Massage® therapists do not perform breast massage.
If I am under the age of 18, my parent or guardian must sign a Minor Consent Form and must be present in the room during the massage session.
As further explained below, I understand that I may end the session at any time if I feel uncomfortable for any reason.

TERMS & CONDITIONS

Please review and sign at the bottom of the page. (Please ask us if you have any questions, concerns or need additional information):
BY SIGNING BELOW, I ACKNOWLEDGE AND AGREE TO ALL OF THE FOLLOWING TERMS: The Studio identified below is independently owned and operated by the Operator. Elements
Therapeutic Massage, LLC, the franchisor of the Elements Massage® franchise system (“ETM”), does not own or operate the Studio and is not contractually or otherwise liable to any individual whom
receives services at the Studio. I acknowledge and understand that the Studio’s massage therapists and other personnel are employees of Operator and are not employed by ETM. Massage and
bodywork therapy is not a replacement for medical care and 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 Studio of all known medical conditions and will keep the Studio updated as to any changes in my condition going forward. If I experience any pain or discomfort during
the session, I will immediately inform the therapist so that the session may be adjusted to my level of comfort or I may end the session altogether.
ASSUMPTION OF RISK, RELEASE, WAIVER OF LIABILITY, INDEMNIFICATION, AND MEDIATION – By signing below, I hereby waive all claims, assume all risks and liability, and release,
indemnify, and agree to defend Operator, ETM, their subsidiaries and affiliates and their respective owners, officers, directors, employees, representatives, successors, and assigns (each a
“Released Party”), from liability for any injury, claim, cause of action, suit, demand, and damages (each a “Claim”) (including, without limitation, personal injury, economic loss, and punitive or
consequential damages) arising in whole or in part out of my receipt of services at the Studio, including any Claims based on any Released Party’s negligence, breach of any contract and/or
express or implied warranty, or any and all violation(s) of applicable federal law or law of the state in which the Studio is located, whether known or unknown as of the date hereof. If any damages
are nevertheless enforced against any Released Party, such damages shall exclude punitive or consequential damages and shall be limited to the total amount I have paid to Operator in the twelve
(12) months preceding the Claim. As a precondition to initiating any legal proceeding against any Released Party, I agree to engage in mediation of any Claims with the Operator. If any terms of this
provision are held to be invalid, illegal, or unenforceable, all other terms shall remain in full force and effect.
CLIENT BEHAVIOR - Any illicit or sexually suggestive comments or actions made by me will result in immediate termination of the session and I will remain responsible for full payment. I will
additionally be prohibited from receiving services at other Elements Massage studios.
NON-SOLICITATION - I will not solicit, recruit or encourage any person employed by the Studio for employment or the provision of services outside of the Studio.
CANCELLATION POLICY - Appointments may be cancelled without charge up to 24 hours before the appointment’s scheduled start time. Cancellations made with less than 24 hours’ advance notice
may be charged a Late Cancellation fee up to the full cost of the booked session as determined by studios and by signing below, I authorize Operator (and its successors and assigns) to charge my
credit card or checking account on file in the event of such late cancellation.
CLIENT INFO - Please be advised your personal information (including but not limited to your visit history, buying habits, personal preferences, and the contact information you have provided on this
Intake Form or that you have entered into a scheduling program) will be shared with ETM, its affiliated companies, third-party vendors, and other Elements Massage® studios for various purposes,
including but not limited to providing, maintaining, and improving services at Elements Massage® studios. ETM’s privacy policy is available at www.elementsmassage.com. The Studio complies with
applicable laws that protect the privacy and security of client’s personal data.
COMMUNICATIONS POLICY - Operator, ETM, and/or their vendors may occasionally send promotional opportunities and marketing materials via e-mail, phone calls, text messages, faxes, and
other electronic messages. If you do not wish to have your contact information used to promote Elements Massage® products or services, you can opt-out of receiving such communications by
checking the relevant box below. If Operator, ETM, and/or their vendors have sent you a promotional e-mail, you may send a return e-mail asking to be omitted from future e-mail communications or
unsubscribe by following the link found at the bottom of the e-mail communication. Subject to applicable law, this opt-out does not apply to appointment reminders and communications about service
purchases, billing information, late charges, product service experience or other transactions.
I do not wish to receive promotional opportunities.
Name of Studio Operator: (“Operator”)
Studio Address: (“Studio”)
Signature I acknowledge I have received notice of (or have been given the opportunity to review) Date MT Initials
Operator’s privacy and security policy.
_____________(initial here)
©2019 Elements Therapeutic Massage, LLC. All Rights Reserved. Massage session includes time for consultation and dressing. Each Elements Massage® studio is independently owned and operated. test
Last Modified: February 12, 2019 7:24 AM
 CLIENT INTAKE FORM
Health History & Consultation

HEALTH HISTORY
Please check all current / past conditions that apply:

headaches seizures fibromyalgia wear contact lenses

muscle / joint pain bruise easily varicose veins jaw clenching/teeth grinding
stroke/heart attack high/low blood pressure active cancer numbness/tingling, if so, where:
blood clots diabetes osteoporosis
Please list any other medical conditions and/or any medications you are currently taking:

Please list any accidents, injuries and/or surgeries in the last two years and include date of occurrence:

Are you pregnant? Postpartum 6 months or less? Do you have any allergies and/or skin sensitivities?
Yes No If yes, how many weeks:________ Yes No DOB:____________ Yes No If yes, please list:
In the chart below, please indicate the parts of your body that will be massaged or the areas of your body that will be avoided during the session

• Indicate yes or no and initial to consent for each of the shaded areas of the body
• Place an X on any other areas to be avoided.
• Place a CIRCLE around areas that need extra attention.

Front Scalp Back

initials Yes / No
Pectoral Muscles
Yes / No initials

Abdominal Muscles
Yes / No initials Glutes
initials Yes / No

Feet
Yes / No initials

By signing this form, I consent to its policies, the selected techniques, and the selected areas of my body to be massaged as defined by the therapist. I further acknowledge and agree that
I will notify the Studio if I wish to update which areas of my body I consent to have massaged during sessions, which techniques are to be used, or have changes in my health history.
Client Signature: Printed Name Date:

SESSION CONSULTATION
To Be Completed By Massage Therapist
Please indicate the type of massage techniques to be used:

I have reviewed the definitions for Pectoral Muscles, Abdominal Muscles, and Glutes with the client verbally.
LMT Signature: LMT License # (if required by state): Date:

Name of Studio Operator: (“Operator”)

Studio Address: (“Studio”)
©2019 Elements Therapeutic Massage, LLC. All Rights Reserved. Massage session includes time for consultation and dressing. Each Elements Massage® studio is independently owned and operated. test
Last Modified: February 12, 2019 7:24 AM