MEDICAL INTAKE FORM

Due to the COVID-19 pandemic, we are requiring all of our guests, new and returning, to complete our newly updated Intake Form. This will assist us in starting your session on time.

 

Once the form is completed and the "Submit" button has been selected, a confirmation message will appear on your screen.

 

*It is important to complete this form prior to your arrival. Time to complete the form while in office will be deducted from your session time. 

 

This form will need to be completed yearly in order to keep our records up to date.

Medical Questionnaire

Please fill out the following form to help us understand your physical condition.

Have you experienced Professional massage in the past?
What level of Massage pressure do you prefer?
What is your normal daily routine?
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Do you work out?
Please check the areas that you are NOT comfortable receiving a massage.
Please check any of the Medical conditions that are currently applicable to you.
Are you currently taking medications, painkillers, and/or supplements that would contraindicate therapeutic massage?

COVID-19:

Due to COVID-19, we are temporarily limiting the number of daily appointments in order to control the number of people within the office.

 

If you are experiencing a fever, cough, or sore throat, please reschedule your appointment for when you are no longer symptomatic.
If you have been to a COVID-19-impacted area or have been in close contact with a person infected with COVID-19, we ask that you please reschedule your appointment for 14 days past the date of contact.
Please note, we are requesting that clients wear face coverings throughout the entire visit.

 


COVID-19 Cancellation Policy:

Amid the ongoing uncertainty of COVID-19, we have modified our cancellation policy to offer greater flexibility to all our clients. We hope this will alleviate any stress and hesitation you have about your upcoming appointment.

 

If you need to reschedule for whatever reason, and especially if you are not feeling well, we understand and request you to please contact us as soon as possible to reschedule. To further support you, there will be no penalties for cancellations.

 

We understand that unanticipated events happen occasionally in everyone’s life. In our desire to be effective and fair to all of our clients and out of consideration for our therapist time, we have adopted the following policies:

 

How should I Cancel / Reschedule my appointment?

• If you are outside of the 24-hour window, log into your "Schedulicity" account to cancel and reschedule.

• If you are inside of the 24-hour window, the system will not allow you to make any changes to the scheduled appointment. Please send an email to pttm.info@gmail.com as soon as possible.

• You can also leave a voicemail by calling the direct office phone line: 443.583.0202. *We do not have a receptionist. Voicemails may not be received prior to your scheduled time.

• Email is the best way to communicate with us.

 

Arriving Late:
• If you have not arrived or called after 15 minutes, you will be considered a “No Show”.
• Appointment times have been arranged specifically for you. If you do arrive late, your session will be shortened in order to accommodate others whose appointments follow yours.
• Depending upon how late you arrive, your therapist will then determine if there is enough time remaining to start and conduct a session.
• Regardless of the length of the treatment actually given, you will be responsible for the “full” session.
• Out of respect and consideration to your therapist and other customers, please plan accordingly to arrive on time.

 

Massage Session Guidelines and Confidentiality:
• The therapist does not share information about the session with others.
• If the guest would like the therapist to send a note to a physician, the guest must make the request in writing.

Treatment
• The guest determines which pieces of clothing to be removed.
• The therapist discusses what is most helpful for the specific treatment; however, the guest makes the final decision.
• The guest determines which areas not to treat (i.e., no foot strokes due to being ticklish)
• The guest will remain covered at all times and only the area being worked on will be uncovered.
• The guest needs to communicate the pain level to the therapist.
• Treatment is provided in a designated space that is used solely for massage and where guest’s privacy is assured.
• No sexual behavior/intonation is tolerated.

Payment
• Payment is due at the time service is rendered.
• All sales are final after three days on all Premiere Promotional gift cards/certificates.
• Premiere Promotional gift cards/certificates expire 6-months from the date of purchase.
• Premiere Card packages expire 1-year from the date of purchase.

 

Agreement:
We agree to adhere to the specified boundaries. If for some reason the guest cannot adhere to the boundaries, the therapist will discuss a course of action that may result in a right to refuse treatment of the guest.

I understand that the massage or bodywork, 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 practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage or bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialists for any mental or physical ailment of which I am aware. 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 given should be construed as such. 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. I agree to keep the practitioner updated as to any changes in my medical profile and I understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually suggestive behavior during the session will not be tolerated, and I will be liable for payment of the scheduled appointment.

I certify that the information I have provided is accurate to the best of my knowledge and agree to the business, terms policies, and conditions.

Your Signature

Emergency Contact Information
Massage History
Health History
Current Medication & Habits
Policies and Guidelines