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Form Is Required Prior To Appointment

TDLR Required Form

The state of Texas requires this in-take form prior to any massage or body treatment as a first time client.

Have you had massage therapy before?
Are you prgnant?
Are you breastfeeding?
Do you have a history of any of the following?
Complimentary Aromatherapy?
Please read before signing.
The Texas Massage Therapy Board and Texas Department of Licensing and Regulation rules specify a consultation documentation must be provided and include guidelines to help ensure the protection and safety of the client and massage therapist.

Draping will be used during the session and, aside from the head and neck, only the area being worked on will be uncovered. At no time will breasts, genitals, or gluteal cleavage be undraped without client consent (this is not a modality we offer).

The client or massage therapist may end the massage session at any time if they feel uncomfortable for any reason.

The massage the
rapist must immediately end the session if a client initiates any verbal or physical contact that is sexual in nature.
 

If you experience pain or discomfort during your massage, please inform your massage therapist immediately. You are encouraged to ask for less or more pressure to suit your needs.

Clients 17 and under must be accompanied by a parent or legal guardian and remain in the building during the entire session. Clients 15 and under must have a parent or legal guardian remain in the treatment room for the entirety of the treatment. Informed written consent must be provided by a parent or legal guardian for any client under the age of 18 years.

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I understand that the massage I receive is provided for basic relaxation and relief of muscular tension. I further understand that massage is not a substitute for a medical exam, diagnosis or treatment. Because massage should not be performed for certain medical conditions, I affirm that I have answered these questions honestly and have stated any known medical conditions. I agree to keep my therapist informed of any changes to my medical profile and understand that there is no liability on the therapist’s part or on Good Vibrations Mobile Massage Therapy LLC’s part should I fail to do so.

Thanks for submitting!

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