New Client Intake

Please fill this in before your first appointment. When you press Send at the end it opens your own email with the answers filled in.

Legal Name: Vital Rejuvenation Med Spa, LLC · Doing Business As: RMH Massage Therapy

Client Information

Primary Complaint and Pain Location

Cardiovascular

Check each box that applies to you. Checking a box means you have this condition. If you are unsure, leave it unchecked and discuss it with Matt before treatment.

Neurological

Check each box that applies to you. Checking a box means you have this condition. If you are unsure, leave it unchecked and discuss it with Matt before treatment.

Musculoskeletal

Check each box that applies to you. Checking a box means you have this condition. If you are unsure, leave it unchecked and discuss it with Matt before treatment.

Surgery History

Check each box that applies to you. Checking a box means you have this condition. If you are unsure, leave it unchecked and discuss it with Matt before treatment.

Chronic Medical Conditions

Check each box that applies to you. Checking a box means you have this condition. If you are unsure, leave it unchecked and discuss it with Matt before treatment.

Skin Conditions

Check each box that applies to you. Checking a box means you have this condition. If you are unsure, leave it unchecked and discuss it with Matt before treatment.

Lymphatic Conditions

Check each box that applies to you. Checking a box means you have this condition. If you are unsure, leave it unchecked and discuss it with Matt before treatment.

Cancer History

Check each box that applies to you. Checking a box means you have this condition. If you are unsure, leave it unchecked and discuss it with Matt before treatment.

General Safety

Check each box that applies to you. Checking a box means you have this condition. If you are unsure, leave it unchecked and discuss it with Matt before treatment.

Medications, Surgery Details and Anything Else

Practice Policies

Type your initials next to each policy. Your initials indicate you have read and agree to the policy.

Medical Disclosure

I understand that I must inform Matt of all relevant medical conditions, injuries, surgeries, medications, and changes in health status. Withholding medical information increases the risk of injury and may make treatment unsafe.

Risks of Treatment

I understand that soreness may occur for approximately thirty six hours after treatment. If soreness lasts longer than forty eight hours, I must inform Matt. I will communicate any sensation that feels unsafe, intolerable, or significantly different from my typical experience.

Contraindications and Right to Refuse Treatment

I understand that certain medical conditions may require treatment to be modified, postponed, or refused. Matt may refuse or discontinue treatment if it is medically unsafe to continue.

Tools and Techniques

I understand that treatment may include therapeutic techniques and tools within scope of practice. I may decline any tool or technique at any time.

Arrival Expectations

I understand that I am expected to arrive at least five minutes before my scheduled session. If I arrive late, my session will still end at the scheduled time in order to remain fair to the next client.

Cancellation Policy

I understand that I may cancel or reschedule without penalty until 9 PM the evening before my scheduled session. Cancellations after 9 PM are recorded as one cancellation. A no call no show is recorded as two cancellations. After three recorded cancellations in a calendar year, scheduling privileges are suspended unless Matt authorizes an exception.

Illness Policy

I understand that if I am actively sick with fever, vomiting, diarrhea, or symptoms of infection, treatment cannot be performed. I understand that I should be symptom free for forty eight hours before contacting the practice to reschedule.

Professional Boundaries

I understand that this practice provides medically therapeutic massage services only. Professional behavior is required at all times. Any attempt to initiate physical sexual contact or engage in inappropriate physical or verbal behavior results in immediate termination of the session and permanent dismissal from the practice.

Consent to Treat

I voluntarily consent to receive medically therapeutic massage services from RMH Massage Therapy. I understand that I may request changes in pressure, positioning, or technique at any time. I understand that treatment may be modified or discontinued if it is medically unsafe to continue.

By sending this, I confirm that the information provided is accurate to the best of my knowledge and that I have read and initialled each policy listed above.