Helpful Forms
The following forms are designed to help us work together more easily:
Health History Form Water Lily Massage
Personal Information
Name_________________________________Cell___________________Home_____________
Address____________________________________City________________________________
State/Zip_________________________________ Date of Birth__________________________
Emergency Contact____________________________________Phone_____________________
The following information is confidential and will be used to provide you with an effective, positive and safe experience. Please answer to the best of your knowledge.
- Is this your first professional massage? yes no
- Do you have any difficulty lying on your back, front or side? yes no
- Do you have sensitive skin or scent allergies? yes no
- Are you wearing dentures or a hearing aid? yes no
- Is there any area of your body where you are experiencing tension, stiffness, pain or other discomfort? If yes please describe ___________________________________________________
- List medications you are taking for physical conditions (heart, seizure, diabetes, high BP)
_______________________________________________________________________
- Please check any condition that applies to you:
( ) contagious skin condition ( ) phlebitis ( )open sores or wounds
( ) HIV ( ) joint disorder ( ) recent accident or injury
( ) osteoporosis ( ) recent surgery ( ) heart condition
( ) artificial joint ( ) headaches ( ) Athlete’s foot
( ) diabetes ( ) cancer ( ) current fever
( ) numbness ( ) fibromyalgia ( ) Acne, planters warts
( ) high blood pressure ( ) varicose veins ( ) Multiple Sclerosis
( ) pregnancy (how far along___)
- I am here for ( ) relaxation ( ) pain management ( ) stress reduction
- I prefer ( ) light pressure ( )medium pressure ( ) deep pressure
Is there anything else about your health history that would be useful to your massage therapist? à
___________________________________________________________________________________________________
Informed Consent
I understand that the massage given to me by __Water Lily Massage__ is for the purpose of (stress reduction, pain reduction, relief from muscle tension, increasing circulation, or other conditions.
I understand that the massage therapist does not diagnose illness or disease and does not prescribe medical treatment or pharmaceuticals, nor are spinal manipulations part of massage therapy.
I understand that massage therapy is not a substitute for medical care and that it is recommended that I work with my primary caregiver for any condition I may have.
I have stated all my known physical constrictions and medications and I will keep the massage therapist updated on any changes.
“I understand that close contact with people increases the risk of infection from COVID-19. By signing this form, I acknowledge that I am aware of the risks involved and give consent to receive massage from this practitioner.”
“I understand that my name and contact information might be shared with the state health department in the event that a client or practitioner at this facility tests positive for COVID-19. My contact details will only be shared in the event they are relevant based on suspected exposure date, and only for appropriate follow-up by the health department.”
I have read and understand my Bill of Rights. *
Signature_______________________________Date______________________________
General Liability Release Form
This is a standard release of liability for our massage therapy work together.
If you are a new client, please complete this form and bring it along to your first session.
This form will help you clarify your goals for your overall health and vitality, including our time together.
This form allows a parent or legal guardian to give permission to perform massage on a minor client.
If you'd like to set up massage for your company as a one-day treat or as a recurring benefit, this contract lays out the details of our agreement.
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