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Transformational Bodywork Course
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| Policies
& Intake |
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Responsibility for time scheduled. If you need to cancel a session, we need to know 24 hours in advance so that we may offer the session time to others. Any sessions canceled or rescheduled with less than 24 hours notice will be subject to a 50% charge, except in case of sudden illness, accident, or emergency. If you paid in advance and do not show up for your appointment, we reserve the right to keep all monies paid. If you arrive late, you will have the remaining time of the scheduled session. Guarantee concerning prepaid appointments. If we are unable to honor an appointment for which you have prepaid, we will refund the full amount paid for that session. This assumes that efforts to reschedule were made and were unsuccessful, and that if it was you who needed to reschedule, you gave us at least 24 hours’ notice. If we need to reschedule your appointment, we will give you at least 72 hours’ notice (except in case of emergency) or will refund the amount paid for that session. Responsibility regarding contagion. You will cancel or reschedule immediately if you have or suspect you have a contagious illness, rash, or other contagious condition. No payment is required in such cases. We do still appreciate your letting us know as soon as possible so that we may open up your appointment time for others! Full reporting of medical conditions. On your intake form or in your intake interview, you will disclose all known medical conditions and medications, since many conditions (not just the ones you might think) have implications for whether and how massage may safely proceed. Preparation/hygiene. You will be reasonably clean and not under the influence of drugs or alcohol. Arriving under the influence of drugs or alcohol is grounds for termination of the session (with payment for the full scheduled time still due). Respect for the practitioner. Sexual conduct or innuendo will not be tolerated and will be grounds for immediate termination of the session (with payment for the full scheduled time still due). Respect for other clients. You (and your
cellphone J) will be quiet enough not to disturb clients in adjoining
rooms.
Confidentiality. All information shared is kept confidential unless one of the following conditions applies: 1. You have signed a written release. Professionalism. You will be treated with respect, dignity, and professionalism. Specifically, we provide 1. Clean, safe equipment; TIBIA Massage Studio~ 608.238.7468 Signature ____________________________ Name (printed) _______________________ Date ____________________
TIBIA Massage Studio Download
PDF version-click here Name: ________________________________________________ Birth Date: _____________ Address: ______________________________________________________________________ City: ___________________________________ State: __________ Zip:__________________ Home: ___________________ Cell: ____________________ Work: _____________________ Email: ________________________________ Physician: _____________________________ Previous experience with massage: _________________________________________________ Primary reason for appointment / areas of pain or tension: _______________________________ ______________________________________________________________________________ Emergency contact : _____________________________________________________________ Please mark (X) for all conditions that apply now, ___ abdominal or digestive problems ___ allergies, sensitivities ___ arthritis, tendonitis ___ asthma or lung conditions ___ birth control, IUD ___ blood clots ___ cancer, tumors ___ chronic pain ___ constipation, diarrhea ___ dental bridges, braces ___ depression ___ diabetes ___ fatigue ___ headaches, migraines ___ hearing problems, deafness ___ heart, circulatory problems ___ hernia ___ high/low blood pressure ___ infectious diseases ___ injuries or face or head ___ jaw pain, TMJ problems ___ muscle, bone injuries ___ muscle or joint pain ___ numbness or tingling ___ pregnancy ___ rashes, athletes foot ___ sinus problems ___ sleep difficulties ___ spinal column disorders ___ sprains, strains ___ tension, stress ___ varicose veins ___ vision problems, contact lenses ___ other medical conditions
Current medications, including aspirin, ibuprofen, herbs, supplements, etc: _________________ ______________________________________________________________________________ _____________________________________________________________________________ ______________________________________________________________________________ Surgeries: ____________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Accidents: ____________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Please list all forms and frequency of stress reduction activities, hobbies, exercise or sports participation: __________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ INFORMED CONSENT I understand that the bodywork I receive is provided for the basic
purpose of relaxation and therapeutic relief of muscular tension.
If I experience any pain or discomfort during the session, I will
immediately inform the practitioner so that the pressure and/or
strokes may be adjusted to my level of comfort. I further understand
that bodywork should not be construed as a substitute for medical
examination, diagnosis, or treatment. I understand the 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 should be construed
as such. Because bodywork should not be performed under certain
medical conditions, I affirm that I have stated all my known medical
conditions, and answered all question honestly. I agree to keep
TIBIA updated as to any changes in my medical profile and understand
that there shall be no liability on TIBIA’s part should I
fail to do so. Client Signature: _____________________________________ Date: ____________ Practitioner Signature: _________________________________ Date: ____________
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