Name
*
Date of Birth
*
/
Month
/
Day
Year
Date
Address
City/State/Zip
*
Phone
Email
*
example@example.com
How did you hear about us?
Would you like to receive emails from us? (Promotions and information, no spam and your email address isn't shared with anyone else)
Estimate how long has it been since your last professional massage?
Do any of the following apply to you: Cancer, Headache/Migraines, Arthritis, Diabetes, Spinal Problems, Stroke, Neuropathy, High/Low Blood Pressure, Joint Replacement, Fibromyalgia, Heart Attack, Kidney Dysfunction, Blood Clots, Blood Thinners, Numbness, Sprains or Strains and anything else that we may need to be aware of? If none, just write no.
*
What type of pressure do you prefer?
Is there any areas that you would like for us to avoid? (Face, scalp, feet, etc.)
Do you have any general areas of discomfort?
Have you any recent injury/surgery? Please explain if yes.
*
Are you pregnant? If yes, how far along and have you had any complications?
*
Do you have any allergies/sensitivities/medications that we need to be aware of? If yes, please describe.
*
Your massage today may include hot towels, aromatherapy and a hot pack all for no extra charge! However, if you'd like to increase your experience we have several addons: Hot Stones ($10), Facial Cold Stones ($10), Foot Scrub ($15), Dry Brushing ($20 and you keep your brush!), Cupping ($10). If you'd like any, please indicate below or you can let us know before your service.
Disclosure and Consent for Massage Therapy, Massage Cupping and Gua Sha: It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status. I understand that Sevierville Massage Therapy, LLC has provided this form as a reference and is not held liable for any services provided. Massage Cupping and Gua Sha are therapeutic decompression techniques used by massage therapists for the relief of muscular pain, tension, and congestion. These techniques are used to draw out congested fluids and toxins to the surface tissue layers, allowing for fresh blood and lymph circulation. The resolution of stagnation and granulation in the tissues often brings an immediate relief from pain. Massage Cupping uses negative pressure created within a specialized glass or rubber cup that is applied to the affected body part. The pressure can be deep to provide relief from tension, pain and injuries. A more gentle pressure increases lymph flow, circulation and relaxation. Gua Sha is similar to cupping in results, but a round-edged tool is used in strokes to pressure specific areas of muscle pain. There is a possibility of discoloration that can occur from the release and clearing of stagnation and toxins from the body. The reaction is not bruising, but the cellular debris, pathogenic factors and toxins being drawn to the subcutaneous layers for dissipation by the circulatory system. The discoloration, or sha, will dissipate as soon as a few hours or up to 1 week, and in relation to after care activities. It is important to drink plenty of water to stay hydrated, and avoid vigorous exercise for at least 6 hours after treatment. Avoid exposure to extreme temperatures, including cold, wet and/or windy weather conditions, hot showers, baths, saunas, hot tubs, for at least 6 hours after treatment. I understand that all treatments at this facility are therapeutic in nature. I agree to communicate to the therapist any physical discomfort or draping issues during the session. If I choose to experience cupping therapy and/or Gua Sha during treatments, I understand the potential side-effects and the after-care recommendations. *Policies* *Cancellation-If you cancel your appointment same day or no call/ no show you must pay a $25 fee before you are able to return. *Inappropriate comments or behaviors will result in the therapist ending the treatment and you will be responsible for the full amount of service. I have read, understand and will follow all the information stated above and will not hold the practitioner responsible. * * *Type your full name to indicate that you understand.
*
Submit
Should be Empty: