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    Information About You

    Your Contact Information

    Emergency Contact Information

    Questionnaire
    Please answer the questions in this section to the best of your ability.

    Medical information

    Pain Areas

    Please indicate areas of the body where you are experiencing pain. Rate on a scale of 1 (minimal pain) to 10 (extreme pain).
    PLEASE FEEL FREE TO EXPOUND ON THE ANSWERS TO THESE QUESTIONS  
    Answer the following questions with Y/N

    CONSENT AND SUBMISSION

    1. DRAPING:  Draping will be used through the session unless otherwise agreed to by both the client and the massage therapist. 
    2. CLIENT DISCOMFORT AND CESSATION:  If during the massage, the client is uncomfortable for any reason, the client may ask the massage therapist to cease the massage and the session will end immediately. 
    3. INAPPROPRIATE CONTACT:  Should the client engage in any verbal or physical contact with the massage therapist with sexual intent, the coaching will end immediately, with no refund. Full charges will apply. 
    4. INFORMATION UPDATES:  Should any of the intake information change, the client and massage therapist both agree to update the information. 
    5. REGULATORY AGENCY:  The regulatory agency for massage is:
      Texas Department of State Health Services
      1100 West 49th Street, Austin, TX 78756-3183
      (512) 834-6616 
    6. CONTRAINDICATIONS:  I understand that if I have a specific medical condition or specific symptoms, massage/bodywork may be contraindicated. 
    7. PRIMARY CARE PROVIDER REFERRAL:  A referral from my primary care provider may be required prior to service being provided. 
    8. PURPOSE OF SERVICE:  I understand that the massage/bodywork I receive is provided for the basic purpose of relaxation and relief of muscular tension. 
    9. PAIN/DISCOMFORT NOTIFICATION:  If I experience any pain or discomfort during my session(s), I will immediately inform the practitioner. 
    10. NOT A MEDICAL EXAMINATION, DIAGNOSIS, OR TREATMENT:  I further understand that massage/bodywork is not a medical examination, diagnosis, or treatment and that I should see a physician or other qualified medical specialist for any mental or physical illness. 
    11. MASSAGE/BODYWORK PRACTITIONERS NOT DOCTORS:  I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session will be construed as such. 
    12. PATIENT DISCLOSURE:  Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. 
    13. UPDATING PRACTITIONER:  I will keep the practitioner updated as to any changes in my medical profile. 
    14. ILLICIT OR SEXUALLY SUGGESTIVE REMARKS OR ADVANCES:  It is also understood that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for full payment of that session.
    BY CLICKING "AGREE AND SEND", YOU ARE CONFIRMING THAT (A) THE ABOVE INFORMATION IS ACCURATE, (B) YOU AGREE TO THE "CONSENT AND SUBMISSION" SECTIONS 1-14 ABOVE, (C) YOU AGREE TO INDEMNIFY PAMPERING PROS, AND ANY REPRESENTATIVES THEREOF, FOR ANY ISSUES THAT RESULT FROM INACCURATE INFORMATION, OR AS A RESULT (WHETHER DIRECTLY, INDIRECTLY, OR CONTRIBUTIVELY) OF ANY SERVICES RENDERED BY ANY PAMPERING PROS REPRESENTATIVE, (D) YOU UNDERSTAND THAT MASSAGE, REFLEXOLOGY, AROMATHERAPY, AND ALL OTHER SERVICES PROVIDED BY PAMPERING PROS ARE BEING PERFORMED VOLUNTARILY, AND (E) YOU ARE VOLUNTARILY ACCEPTING SUCH SERVICES.
     I HEREBY AGREE WITH ALL THE ABOVE TERMS, AND  GIVE MY CONSENT FOR TREATMENT.
BY CLICKING "AGREE AND SEND", YOU ARE CONFIRMING THAT (A) THE ABOVE INFORMATION IS ACCURATE, (B) YOU AGREE TO THE "CONSENT AND SUBMISSION" SECTIONS 1-14 ABOVE, (C) YOU AGREE TO INDEMNIFY PAMPERING PROS, AND ANY REPRESENTATIVES THEREOF, FOR ANY ISSUES THAT RESULT FROM INACCURATE INFORMATION, OR AS A RESULT (WHETHER DIRECTLY, INDIRECTLY, OR CONTRIBUTIVELY) OF ANY SERVICES RENDERED BY ANY PAMPERING PROS REPRESENTATIVE, (D) YOU UNDERSTAND THAT MASSAGE, REFLEXOLOGY, AROMATHERAPY, AND ALL OTHER SERVICES PROVIDED BY PAMPERING PROS ARE BEING PERFORMED VOLUNTARILY, AND (E) YOU ARE VOLUNTARILY ACCEPTING SUCH SERVICES.
 I HEREBY AGREE WITH ALL THE ABOVE TERMS, AND  GIVE MY CONSENT FOR TREATMENT

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