Complete Booking | Lime Green Lotus

24 hours’ notice is required to cancel or reschedule an appointment.

Please arrive on time to your scheduled appointment. This time slot has now been reserved for you. Due to my tightly booked schedule, I am generally unable to extend your session beyond your original time slot. Regardless of the length of the service actually given, you will be responsible for payment of the full service you scheduled.

If you need to reschedule because you are not feeling well or have any COVID or flu-related symptoms, please contact me as soon as possible to do so. There will be no fee charged for cancellations due to illness.

Client Intake Form

Phone

This field is for validation purposes and should be left unchanged.

Name(Required)

First Last

Phone(Required)

Email(Required)

Emergency Contact Name(Required)

First Last

Emergency Contact Phone(Required)

Consent

I agree for my therapist to follow up with me to ensure my satisfaction with my massage experience

Preferred form of communication(Required)

Phone Call

Text

Would you like email updates from Lime Green Lotus, e.g. on new services and special offers/discounts?(Required)

The following information will be used to help plan safe and effective massage sessions. Please answer the following questions to the best of your knowledge.

Have you had a professional massage before?(Required)

If so, how often?(Required)

Do you have any difficulty lying on your front, back or side?(Required)

If so, please explain.(Required)

Do you have sensitive skin or allergies to oil, lotion, or ointment?(Required)

If so, please explain.(Required)

Do you have any other allergies?(Required)

If none, type "none".

Do you sit for long hours at work or driving, or perform any repetitive movement in your work, sports, or hobbies?(Required)

If so, please describe.(Required)

Do you experience stress in your work, family or other aspects of your life?(Required)

If so, how do you think it has affected your health(Required)

Muscle tension

Anxiety

Irritability

Other

Define "other"(Required)

Is there a particular area of the body where you are experiencing tension, stiffness, pain or other discomfort?(Required)

If so, please identify(Required)

Do you have any particular goals in mind for this massage session?(Required)

If so, please describe(Required)

Medical History

Are you currently under medical supervision?(Required)

If so, please explain.(Required)

Do you see a chiropractor?(Required)

If so, how often?(Required)

Are you currently taking any medications?(Required)

Check all that apply(Required)

Coumadin

Lovenox

Heparin

Plavix

High-dosage aspirin or ginger

Pain killers

Muscle relaxants

Other(s)

Please list any other medications(Required)

Do you have (check all that apply)(Required)

None

Phlebitis/Deep vein thrombosis/Blood clot/Varicose veins

Heart condition (pacemaker?)

Joint disorder/Rheumatoid Arthritis/ Osteoarthritis/Tendonitis

Osteoporosis

Open sores or wounds

Current fever, flu, cold or swollen glands

Recent accident or injury (specify)

Artificial joint

MRSA or other infectious diseases

Epilepsy

Headaches/Migraines

Neuropathy (decreased sensation)

Atherosclerosis

Scoliosis or lordosis; herniated discs (where?)

Hemorrhoids

Aneurism

High or low blood pressure (controlled?)

Fibromyalgia

Easy bruising

Contagious or inflammatory skin condition, cellulitis, boils, skin lesions or abscesses

Surgery within the last year or implants within the last nine months (cheek, chin, breast, pectoral, calf)

Sprain/Strain/Fracture/Break

Carpal tunnel

Tennis/Golfer’s elbow

TMJ

Cancer (cancer medication?)

Diabetes

Pregnancy (which trimester?)

Circulatory disorder

Kidney or liver disorder (including dialysis)

Lumbar spinal stenosis, spondylitis or spondylolisthesis

Irritable bowel syndrome

Specify your recent accident or injury(Required)

Where is your scoliosis or lordosis; herniated discs?(Required)

Is your blood pressure controlled?(Required)

Are you on medication for your cancer?(Required)

Which trimester is your pregnancy?(Required)

Is there anything else about your health history that is important to plan a safe and effective massage session for you and your massage therapist?(Required)

Consent

A parent or legal guardian must accompany clients under the age of 18 and provide informed written consent.

Consent(Required)

I understand that the massage I receive is provided for the basic purpose of relaxation and
relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or stroke may be adjusted to my level of comfort. I further understand that the massage should not be construed as a substitute for medical examination, diagnosis or treatment. I understand that massage therapists are not licensed 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 given should be construed as such. Because massage 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 therapist updated as to any change in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so.

Full Name(Required)

Type your full name to serve as your signature

Today's Date(Required)