Your Name (required)
Your Email (required)
Telephone (required)
Has a physician or chiropractor recommended massage as a treatment for your pain? (required)
YesNo
Has your doctor ever advised against massage? (required)
Is your pain due to a recent trauma? (required)
Are you currently in pain? (required)
Please describe briefly where your discomfort is
Would you like special attention to any body parts during your massage?
Which areas?
Are there any areas of the body you wish to avoid having massaged? HMM therapists DO NOT OFFER FEMALE BREAST MASSAGE.
List all medications you are currently taking
List all surgeries
List any conditions for which you have received medical treatment in the past 12 months
Females Only:
Are you pregnant or think that you may be pregnant?
Acknowledgment and acceptance of disclaimer:
-I understand and accept that massage therapy given here is for the purpose of, but not limited to: Fulfilling a prescription of a treating physician, for a medically necessary condition; for stress reduction, relief from muscular tension, or spasm; or for increasing circulation and energy flow.
-I understand and accept that the Massage Therapist does not diagnose illness, disease, or any other physical or mental disorder. Massage therapy is not a substitute for medical examinations and/or diagnosis. It is recommended that I see a physician for any physical ailment that I might have. Because a Massage Therapist must be aware of existing physical conditions, I have stated all of my known medical conditions and take it upon myself to keep the Massage Therapist updated on my physical health.
-I will respect the time of my Massage Therapist(s) and other clients. I agree to come to my scheduled appointments promptly, barring any unforeseen emergency. I understand that if I cancel later than 8 hours prior to my appointment, I will have to pay HALF the cost of my appointment. If I NO SHOW, I will have to pay the FULL price of the appointment.
-Your massage session will include the use of a combination of Active Release Techniques, Myofascial Release, AIS Stretching,as agreed upon by you and your therapist.
-Your massage will be targeted and customized to treat the area listed above as your chief complaint.
-HMM therapists are not allowed to massage female breasts under any circumstances. The female breast will be draped at all times.
-Draping of the genital area and gluteal cleavage will be used at all times during the session for all clients.
-If uncomfortable for any reason the client may ask the licensee to cease the massage and the licensee will end the massage session.
-The licensee may end a massage session if the licensee feels uncomfortable for any reason.
Agree
Sign here: