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New Client Intake Form

Please fill out the following form prior to your appointment
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Medical History
Indicate if any conditions apply
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Tell me more
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Client Consent and Agreement
  • It is understood that the "I" cited below refers to the client filling and signing this form.

  • It is agreed and understood that Thai Massage is intended for relaxation, and that it is not meant to diagnose, treat or remedy any illness, disease, injury, physical condition or mental disorder.

  • Thai Massage can be an intense form of bodywork, using pressure, stretches and deep tissue manipulation; I agree to communicate my limitation to my practitioner immediately if I do not feel comfortable at any point. I understand that communication between me and my practitioner is very important and I take this seriously. 

  • If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I will not hold my practitioner responsible for any pain or discomfort I experience during or after the session.

  • Because Thai 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. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so.

  • I am aware that Thai Massage is contra-indicated for these conditions, and if I choose to go ahead with Thai Massage, I will not held my practitioner responsible of any adverse effect, or worsening of my situation.
         - Serious heart condition, cancer, tumors or osteoporosis.
         - Artificial joint such as hip or knee replacement.
         - Joint dislocation or bone fracture.
         - Open wounds, healing injuries, injection sites, skin rashes, eczema, psoriasis or shingles.
         - Varicose veins.
         - Pregnancy.
         - Contagious illness.
         - Under the influence of drugs or alcohol.
         - High Blood pressure (applicable for inverted postures and wind gates only).
         - Operated area less than 3 months old.
         - Big meal has been eaten within 3 hours to the massage (applicable for abdomen massage only).
         - Diarrhea (applicable for abdomen massage only).

  • Traditional Thai bodywork is strictly non-sexual. Under extenuating circumstances, either party reserves the right to immediately terminate the session. I also understand 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 payment of the scheduled appointment.

  • Clients under the age of 16 must be accompanied by a parent or legal guardian during the entire session. Informed written consent must be provided by parent or legal guardian for any client under the age of 18.

  • Except in cases of emergency, I agree to pay for 50% of my appointment's fee if cancelled within 24hrs.

  • Except in case of emergency, I agree to pay 100% of my appointment's fee if I do not show up for my appointment.

  • Cancellation and no show policies apply to the Gift Certificates.

  • By signing this release, I hereby waive and release my practitioner from any and all liability, past, present, and future relating to Thai massage therapy and bodywork.
     

You may not be able to sign this form if you are using your cellphone.

In this case, skip the signature section and submit your form.  

Thanks for submitting!

Lou Piché
Traditional Thai Massage
Natural Health & Nutrition Consultation
Holistic Allergy Testing
wildnesshealing@gmail.com | 778.348.7348 | www.wildnesshealing.com