Click this text to edit. Tell users who you are or what you do.

New Client Intake Form

Are you over the age of 18?*
Minors under the age of 18 must make prior arrangements to have a parent or guardian present. Children under 16 must have a parent present at all times.
In case of a major or minor life threatening emergency, in which you are incapacitated or need medical care, who would you like us to contact? Please include name, relationship and telephone number(s).
In case we need to contact your doctor for more information or in an effort to help you with a particular issue, please include your doctors name and number.
Checkbox List*
Please check all that apply
Checkbox List (Continued)*
Please check all that apply.
What are you allergic to? Do you have Osteoarthritis or Rheumatoid arthritis? How often do you have headaches are migraines? What is your current course of treatment? Where and how often do you have pain? Please elaborate on surgeries and pregnancies.
What position do you sleep in?*
What are your goals for your session?
Desired Massage Pressure*
Please be advised we use light to medium pressure for Swedish Massages and Medium to Deep for Deep Tissue Massages. No heavy pressure or deep tissue work will be done during a Swedish Massage. Swedish Massages are for relaxation only.
How would you rate the pain in your neck?*
Please rate your pain on a scale of 0 to 10. (0 is no pain, a 10 is the worst pain you have ever felt in your life.)
How would you rate the pain in your back?*
Please rate your pain on a scale of 0 to 10. (0 is no pain, a 10 is the worst pain you have ever felt in your life.)
How would you rate the pain in your shoulders?*
Please rate your pain on a scale of 0 to 10. (0 is no pain, a 10 is the worst pain you have ever felt in your life.)
How would you rate the pain in your arms?*
Please rate your pain on a scale of 0 to 10. (0 is no pain, a 10 is the worst pain you have ever felt in your life.)
How would you rate the pain in your hips?*
Please rate your pain on a scale of 0 to 10. (0 is no pain, a 10 is the worst pain you have ever felt in your life.)
How would you rate the pain in your legs?*
Please rate your pain on a scale of 0 to 10. (0 is no pain, a 10 is the worst pain you have ever felt in your life.)
How would you rate the pain in your feet?*
Please rate your pain on a scale of 0 to 10. (0 is no pain, a 10 is the worst pain you have ever felt in your life.)
Face*
Please give consent for massage in this area.
Scalp*
Please give consent for massage in this area.
Feet*
Please give consent for massage in this area.
Pecs(Armpits up to the collar bone)*
Please give consent for massage in this area.
Glutes (Hip area)*
Please give consent for massage in this area.
Abs*
Please give consent for massage in this area.
Arms*
Please give consent for massage in this area.
Legs*
Please give consent for massage in this area.
Neck*
Please give consent for massage in this area.
Please elaborate or say "None."
Cancellation Policy*
I acknowledge that I will adhere to the cancellation policy. In the event that I cancel an appointment, I will give 24 hours notice in the event I need to cancel or change and appointment. In the event that I cancel within 24 hours and I call to change or reschedule an appointment, I understand Fire & Ice Therapeutic Massage reserves the right to charge me 50% of my appointment cost to reimburse the therapist I am scheduled with for their time. In the event I do not call or show, I understand I will be responsible for the entire amount of the appointment cost and that the therapist and establishment reserve the right to refuse to see me again in the event that I, as a client, violate the cancellation policy unless otherwise agreed upon with in conjunction with the therapist.
Consent to Treatment*
I understand, agree, acknowledge and voluntarily accept the risks associated with massage therapy services and the use of the massage facility as is. I hereby release Fire & Ice Therapeutic Massage (including affiliates, associates, agents, independent contractors, and employees) from liability for any claim or injury (Including without limitation personal, bodily, mental injury, property damage, or economic loss), which may result from massage(s). I understand my failure to not disclose to my therapist any pre-existing condition, limitation, or sensitivity releases my therapists of liability in the event I am maimed or injured. I understand it is my duty to inform my therapist of any discomfort during the allotted session. I acknowledge that my assigned therapist may at their sole discretion refuse or discontinue massage services if they do not determine such services to be deemed safe or comfortable to either party. If at any time, I or my therapist feel uncomfortable, I acknowledge that we both have the right to terminate and end the session. I understand that at Fire & Ice Therapeutic Massage, modesty is always respected throughout the duration of the allotted session and that draping will be used the entire time as we aim to maintain a safe, professional, and therapeutic environment for both our staff and clientele.
Please type your name and the current date to agree to our consent.
This site uses Google reCAPTCHA technology to fight spam. Your use of reCAPTCHA is subject to Google's Privacy Policy and Terms of Service.

Thank you! Your message was sent successfully.