O So Relaxed

WELCOME! I would like to make your appointment as pleasant and comfortable as possible. If at any time you have questions
regarding your session, please let me know. Your answers to the following questions will be kept confidential. They will be
seen only by myself and are requested so that I may provide you with better care. If you have a specific medical
condition or specific symptoms, massage may be contraindicated. A referral from your primary care
provider may be required prior to services being provided. Contact contact us at 757-656-9559 with
any questions or concerns.
Name__________________________________________________________________________ Date___________________________
Address________________________________________________________________________Phone (day)______________________
City_____________________________________________ State_____________ Zip________ Phone (eve) ______________________
Age___

D.O.B.____/____/____ Sex_______

E-Mail Address____________________________________________________

Occupation_________________________ What do you do for exercise? ____________________________________________________

Pressure:____________________

Have you received previous massage work?_____________________________________________

How did you hear about us?

Referred By

___________________________________________
_____________________________________________

In Case of Emergency, Contact

_________________________________________

Phone

______________________________

Relationship

__________________

Are you currently under the care of a Physician? Yes No

If yes, name of Physician and reason
_________________________________________________________________________________________________________

Have you had a professional massage before? Yes

No
If yes, how frequently do you get a massage?
________________
______________________________________________________________

If yes, do you have a style or pressure preference?

Specify: light medium firm pressure Other
___________

What type of massage are you seeking today?

Relaxation Deep Tissue Therapeutic
Sports

What do you hope to accomplish from todays

massage?
______________________________________________________________

Are you sensitive to fragrances or perfumes? Yes

No
Do you have any known allergic reactions? Yes
No
If yes, please describe

___________________________________

Pregnancy Senior Detoxification Hot

Stones
Other ___________________________________________________

Any specific areas you would like worked on?

________________________________________________________________________________________________________________

Any major traumas you have had to your body (e.g. accident, fall, etc.). Please include ALL muscle, bone or joint injuries even if not recent:

______________________________________________________________________________________________
Is there anything else I should know?

______________________________________________________________________________________________

_____________________________________________________________________________________________________________________________

Medical History
Are you currently experiencing any of the
following conditions? Flu or Cold
Inflammation Fever Infection
Contagious Disease
Do you suffer from chronic or persistent
pain/discomfort?
Yes No If so, for how long?
____________________________

Do you know what causes/caused it or when the

symptoms seem to get worse or better?
______________________________________
___
Do you see a chiropractor? Yes No
If so, how often?
______________________________________
___
Are you currently under medical care? Yes
No Are you currently taking any prescription
medication?
Yes No If so, name meds and reason
______________________________________
______________________________________
______

Bruise Easily
Varicose Veins
Currently Pregnant Blood Clots
Epilepsy / Seizures Neck / Back Injuries
Diabetes
Paralysis
Fibromyalgia
Numbness
Sprains, Strains
Recent Injuries
What are your common areas of pain or
tension?
______________________________________
______________________________________
______
______________________________________
______________________________________
______
Are there any other health concerns you wish to
discuss today?

Yes No If yes, please describe:

______________________________________
______________________________________
______
Are you aware of any tension holding spots in
your body?
Yes No

Please indicate any condition that you have had

or currently have:
Do you have sensitive skin?
Do you exercise regularly?
Yes No Yes No

Headaches / Migraines Allergies /

Sensitivity Arthritis / Tendonitis

If yes, circle any specific areas you would like

the massage therapist to concentrate on during
the session:
Cancer / Tumors
TMJ Problems
Abnormal Skin Condition
Heart / Circulation Problems
Joint Replacement / Surgery
High / Low Blood Pressure
Major Accident
Lack Of -or- Reduced Feeling / Sensation
__________________

The following sometimes occur during massage. They are normal responses to relaxation and/or touch, and need not be embarrassed nor suppress them.
Movement or release of intestinal gas - crying - laughing - strong emotions - sighing - groaning - yawning - softening of muscle tissue - cognitive or felt
memories - stomach gurgling - need to move or change position. At any time during your session please let me know if there is anything I can do to help
you feel more comfortable.
I understand that the services provided are not a replacement for medical or psychological care and that any information provided is not prescriptive or
diagnostic in nature and is for educational purposes only. I also give my permission for the LMT(s) with whom I work to discuss information pertinent to
my condition(s) and treatment, with my other health care providers.

Client's Signature_____________________________________________________________ Date ____________

O So Relaxed Policy/Procedures/Consent/Release
I understand that massage therapy provided by O So Relaxed Massage Therapist is intended to enhance relaxation,
reduce pain caused by muscle tension, increase range of motion, improve circulation and offer a positive experience
of touch. Any other intended purposes for massage therapy are specified below:
The general benefits of massage, possible massage contraindications and the treatment procedure have been
explained to me. I understand that massage therapy is not a substitute for medical treatment or medications, and that
it is recommended that I concurrently work with my Primary Caregiver for any condition I may have. I am aware
that the massage therapist does not diagnose illness or disease, does not prescribe medications, and that spinal
manipulations are not part of massage therapy. Any inappropriate conduct/behavior will not be tolerated. I
understand that any sessions may be ended immediately. Please reference Refund policy below. I have informed the
massage therapist of all my known physical conditions, medical conditions and medications, and I will keep the
massage therapist updated on any changes. I have received a copy of the therapists policies, I understand them and
agree to abide by them.
I authorize the O So Relaxed Massage Therapist to release all relevant information from my therapeutic massage
sessions to my physician or other healthcare provider(s) as requested. Further I give consent to allow O So Relaxed
to consult with and/or receive similar information from my other healthcare provider(s) in order to facilitate my
treatment(s). I agree to be responsible for any balance(s) for services rendered to me by the LMT.
O So Relaxed has a Cancellation Policy in place and would appreciate if you would acknowledge it. We understand
that life happens but we require that you contact us if you are not able to keep your appointment. All late arrivals
appointment time may be shorten at managements discretion unless prior communication has been made. No Call/
No-show will forfeit appointment rescheduling until all payments have been rendered for missed appointment slot. If
you need to cancel an appointment we require at least 24 hours notice. 50% of the cost of the massage scheduled
will be charged for cancellations within 24 hours and payment must be render prior to rescheduling.
If you have a Massage Gift Certificate with O So Relaxed, please plan ahead in making an appointment. Waiting
until the last few days before your expiration date might make it more difficult in getting in before it expires, so
please call as soon as receiving Gift Certificate. Last minute cancellations and no-shows will result in full service
charges or void gift certificates. Fees are non-refundable and have no cash value on future appointments. Late arrival
and No Call/No Show policy also applies to Gift Certificates.
New Client Information can be obtained on the Home Page of othella.org in the bottom left corner. If you are unable
to retrieve the Intake Forms via the website, please arrive 15 minutes before for your appointment to allow for new
client information to be filled out if you are a new client.
If you are late you will receive only the amount remaining of your scheduled appointment including the time needed
to fill out paperwork. You will be considered a "No Show" if you are not there at your appointment within 15
minutes after the schedule appointment time and if there was no phone call with a message to cancel or reschedule.
If you are not familiar to where our location is we suggest you leave extra early so you will arrive promptly for
your appointment. No show-no massage-no refund. Refund request will be honored within 7-10 business days from
the date of the original refund request via email at obodywork@gmail.com all request will be rendered at the
discretion of management per incident by mail. All purchases made with O So Relaxed or staff are binding through
the admiration of your acceptance of our policies and procedures. All disputes will only be settled through
arbitration. Please contact us if you have any questions about the Appointment and Cancellation Policy 757-6569559.

Clients Signature: _____________________________________________________________Date:_________________

CONTRAINDICATIONS TO
HOT STONE MASSAGE
Hot stone massage is not suitable for everyone. Please review the list of contraindications below. If any of
these conditions apply to you, then you should not receive hot stone massage.
*Blood clots / prone to blood clots
*Bruise easily
*Cancer, chemotherapy or radiations treatments
*Depressed immune system
(lupus, HIV/AIDS, cancer, Epstein Barr, mononucleosis, etc.)
*Diabetes
*Fever
*Heart problems
*Heat Sensitivity
*High Blood Pressure
*Inflamed Skin Conditions
*Nerve Trauma
*Neuropathy
*Open wounds or sores
*Peripheral vascular disorder
*Pregnancy
*Recent Surgery
*Taking medications that have side effects to heat
(Please check with your pharmacist if you are not certain.)
*Varicose veins
*If you have any doubt that hot stone massage is safe for you, please check with your doctor before
receiving this modality.

HOT STONE MASSAGE

CONSENT FORM

I have read the above written information about the possible contraindications to hot stone massage therapy,
especially during pregnancy. In addition, I have discussed this with my physician and have had the opportunity
to ask questions of the massage practitioner and of my physician about the information. I understand the
information and confirm that:
o

o
o

I am aware my conditions/s of ____________________________________________ clearly states this as

one of the conditions listed, which would make it unwise to have hot stone/massage therapy;
given this knowledge I take full responsibility for the outcome in the use of hot stones/massage
therapy
If pregnant: I am experiencing a low-risk pregnancy;
If pregnant: I am receiving medical care including regular check-ups throughout my pregnancy;

If my physician and I have identified any exclusion to the statements above, please list here:
__________________________________________________________________________________________
__________________________________________________________________________________________
I understand that I will be receiving massage therapy with hot stones as a form of adjunctive health care only and
that this is not intended to replace appropriate medical care.
I do forever release O So Relaxed, the owner, the practitioners and their insurers, and their respective officers,
directors, stockholders, successors, employees and agents from all liability of any nature whatsoever, whether
past, present or future for injury or damage which may occur to myself or my family as a result of my receiving
massage therapy with hot stones during this year, and if pregnant this childbearing year.
I agree to hold harmless practitioner of and from all actions, claims, or other legal or administrative action that
has arisen or may arise directly from my participation in this therapy.

Signed:_____________________________________________________________________Date:__________
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Name:_____________________________________________________________________________________