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Wellness History
& Intake Form

Hot Stone Massage
Please check the following conditions you are currently experiencing or have experienced:
All of the information given on my INTAKE FORM is correct and up to date. I take it upon myself to update any pertinent changes in my health during future visits.
This massage is for stress reduction and relief of muscular tension or spasm, and is not a substitute for medical examinations or treatments.
The therapist does not diagnose, treat, or prescribe for any illness, ailment, or disease. While the therapist may assist me in relief of physical or emotional symptoms.
I am aware that this is a non-sexual massage. Any misconduct or inappropriate behavior in that arena will result in immediate termination of the session with full payment due.
I am always in control of my body during my session and will feel free to comment on the comfort or discomfort of the amount of pressure or strokes being used. I can say "stop" at any time.
I will be fully covered with a sheet at all times and only the body part being worked on will be uncovered.
I agree to pay by cash, check, or digital payment after the massage. If my payment is late, I agree to pay a $20 service fee, as well as any additional fines the therapist may incur as a result.
A 24 hours' notice of cancellation is required; otherwise I will be required to pay $15 for either a late cancellation or missed appointment.
If I am going to be late for an appointment, I agree to call as soon as possible and understand that my time may be shortened as a result.
I am to come to my massage session showered or bathed.
I agree to pay all session fees at the time I receive my massage, and if I am using insurance coverage, I will bill the insurance company directly.

Thanks for submitting!

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