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Have you had a Professional Massage Before this Visit?
Reason for today's massage(major complaint)?
What, if any, Treatment have you had for this Condition?
Is there anything that makes the condition worse?
If Yes, Please Explain:
Desired Massage Pressure?
Health Conditions (check box if conditions apply to you)
Heart or Circulation Problems:
Neck or Back Injuries:
Sprains or Strains:
Arthritis or Tendonitis:
Abnormal Skin Condition:
High or Low Blood Pressure:
Describe above checked health conditions:
Other Significant Health Conditions:
What you can Expect in a Professional Massage:
A Safe & Professional Environment & Approach; To be Treated with Respect
To Have Privacy While Undressing & Dressing; To Be Draped Except for the Area Receiving Work
To be Accepted Without Judgment; To be Able to Stop the Therapy At Any Time
To be Listened to Carefully; To Talk, or not to Talk
To Have Control Over How Much Pressure is Used
Massages are scheduled by appointment only and we will make every effort to accommodate the time and date that are requested, however, to ensure maximum availability, please make your appointment in advance. Same day appointments may or may not be available. While we realize that there are sometimes occasions when you will have to cancel an appointment we ask that appointments be cancelled with at least 24 hours notice. We will try our best to confirm with you the day before your appointment. A Valid Credit Card number will be required to reserve your appointment date and time. A cancellation/no show after the 24 hour policy may result in your credit card being charged the full amount of the cancelled service. We value your time, please value ours. This is a non-sexual service. The client agrees to modest draping at all times and any type of sexual advances will not be tolerated. The therapist reserves the right to cancel a session at any time if they feel they are in an inappropriate situation or feel threatened in any way. In the event of the therapist having to cancel due to violation of this policy, the client's credit card will be charged the full amount of the service. Gratuities are not included in the price of your service and are always at the discretion of the client. Payment is due before or at the time of service rendered. You may purchase your services online before your appointment, or at the time of service. We accept cash, gift certificates, Visa, MasterCard, Discover, American Express and PayPal, however, we do not keep cash at the Studio location. If you have an appointment at the Studio we ask that you arrive 15 minutes early. All information provided by the client will be kept in the strictest confidence, according to HIPPA regulations. We respect your privacy and appreciate that you put your trust in us to provide massage services for you. We will not share any information about you with any third party and we will not discuss your treatments with any other third party unless written permission is received by you. If you are 15 minutes late for your appointment you will be given the option to reschedule. If you do not want to reschedule, your treatment will end at the original end time and you will be charged the full amount of the original service. If you are more than 20 minutes late, your appointment will be cancelled. We reserve the right to refuse service for any reason & to require a valid credit card to hold your appointment.
I have Read & Agree To our Policies
Client Informed Consent:
I, (client named above), understand that massage therapy provided by, Erin B. Plott (SC #7777) of Massage Mechanics of SC, is intended to enhance relaxation, reduce pain caused by muscle tension, increase range of motion, improve circulation and offer a positive experience of touch. Any other intended purposes for massage therapy are specified below: The general benefits of massage, possible massage contraindications and the treatment procedure have been explained to me. I understand that massage therapy is not a substitute for medical treatment or medications, and that it is recommended that I concurrently work with my Primary Caregiver for any condition I may have. I am aware that the massage therapist does not diagnose illness or disease, does not prescribe medications, and that spinal manipulations are not part of massage therapy. I have informed the massage therapist of all my known physical conditions, medical conditions and medications, and I will keep the massage therapist updated on any changes. I understand that there shall be no liability on the practitioner?s part due to my forgetting to relay any pertinent information. If I experience any pain or discomfort during the session, I immediately communicate that to the therapist so the treatment can be adjusted. I have received a copy of the therapist?s policies, I understand them and agree to abide by them.
Please Type in Your Name and Today's Date Agreeing to the Above Statements
* Today's Date: