RCMT Intake Form

Name*

Phone*

Date of Birth*

Email*

example@example.com

Sex Assigned at Birth*

Gender / Pronouns*

Address*

Address

Street Address Line 2

City/State/Zip

How did you hear about us?*

Google, Nextdoor, Yelp, Walk-by, Health professional, Friend, Other

Employer*

Occupation*

Primary Physician

Emergency Contact

Relationship

Phone

Are you taking any medication?*

YesNo

If yes, please list name and use:

Are you currently pregnant?*

YesNo

If yes, how far along?

Any high risk factors?

Do you suffer from chronic pain?*

YesNo

If yes, please explain:

What makes it better?

What makes it worse?

Have you had any orthopedic injuries?*

YesNo

If yes, please list:

Please indicate any of the following that apply to you:

Explain any conditions you have marked above:

Have you had a professional massage before?*

YesNo

What pressure do you prefer?*

LightMediumDeep

What type of massage are you seeking?*

RelaxationDeep TissueMyofascialOther

Do you have any allergies or sensitivities?*

YesNo

Please explain:

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

YesNo

Please explain:

What are your goals for this treatment session?*

Please mention any areas of discomfort:

Would you like the use of Essential Oils during your session?

YesNo

If yes, how would you like them used?

AromaticTopicalBoth

Sensations you experience frequently (please select all that apply):

Which aroma(s) do you prefer (please select all that apply):

If any others, please explain:

By signing below, you agree to the following:

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. I understand that there shall be no liability on the therapist’s part should I forget to do so.
If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/strokes can be adjusted to my level of comfort. I will not hold my therapist responsible for any pain or discomfort I experience during or after the session, including any marks left by cupping.
I understand that the services offered today are not a substitute for medical care. I understand that my therapist is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness.
As there are several practicing therapists at Rose Curtis Movement Therapy, I understand that my health information may be shared with these other practitioners only if deemed beneficial to my physical health and healing and if I am in the care of more than one practitioner.
I understand that massage is entirely therapeutic and non-sexual in nature. If any sexual comments or advances are made, the session will be terminated immediately and full payment will be required for the session.
I understand that I am fully responsible for managing my appointment bookings, and if I need to cancel, reschedule, or book a session I will do that through my Square app account. The therapist is not responsible for the client's missed sessions due to the client forgetting to add it to their calendars or not receiving text/email reminders.
Cancellations: 24-hour notice is required for cancellation of an appointment or decrease in amount of time scheduled (for example, changing a 90 minute appointment last minute to a 60 minute appointment). This provides someone else an opportunity to schedule an appointment. If this notice is not given, you will be charged in full for the appointment. Full payment is required within 3 days for the session missed.
Late arrivals: Depending on the time of arrival, the massage therapist will determine if there is sufficient time to start a session. Regardless of the amount of time given, you will be responsible for paying for the full session. Out of respect to your therapist and other clients, please be on time to your appointment.
No Shows: Anyone who misses their appointment for any reason will be considered a No-show, and will be charged in full for their missed appointment. Full payment is required within 3 days for the session missed.
Sickness: Massage is not appropriate care for infectious or contagious illness. Please cancel your appointment as soon as you are aware of an infectious or contagious condition. If it is within the 24-hour notice period, the cancellation fee may be waived.
I understand that, because massage therapy work involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. By signing this form, I acknowledge that I am aware of the risks involved and give consent to receive massage and bodywork from this practitioner.
I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.
By signing this release, I hereby waive and release my therapist from any and all liability, past, present, and future relating to massage therapy and bodywork.

I acknowledge and accept the 24 hour cancellation policy. If I cancel with less than 24 hours notice, arrive later than 15 minutes without alerting my massage therapist, no show, or need to cancel for any reason without giving the required 24 hours notice I am responsible for paying in full for the session within three days.

Client Signature*

I have read and completed this intake form honestly and to the best of my ability and have read and accepted all the required policies and expectations in place at Rose Curtis Movement Therapy.

Client Signature*

Date

Personal Information

Medical Information

Massage Information

Natural Wellness Information (applicable only for sessions with Rose Curtis)