Client Information

Full Name * Date of Birth * Email * Phone * Occupation Emergency Contact Name Emergency Contact Phone

Your Session Goals

What brings you in today? * Pain relief Injury recovery Mobility improvement Stress reduction General maintenance

Pain / discomfort level (1–10) Describe your symptoms or goals

Health History

If you selected any, please explain

Medications

Current medications

Are you taking blood thinners? Recent steroid injections?

Lifestyle & Activity

How many hours per day do you sit? Do you exercise regularly? Do you experience numbness or tingling?

Preferences & Consent

Preferred pressure Light Medium Firm Deep

Areas to avoid / sensitivities

Policies & Acknowledgment

Professional Standards: Take Ten Massage is a professional therapeutic practice. Any inappropriate behavior or requests will result in immediate termination of the session and forfeiture of payment.

Cancellation & Rescheduling: Appointments require 24 hours’ notice to cancel or reschedule. Late cancellations or no-shows result in forfeiture of deposit or 50% of the service price (if no deposit was collected).

Late Arrivals: Late arrivals may shorten your session to respect the next appointment. The full service fee still applies.

Memberships & Packages: Late-cancel/no-show appointments may be counted as a used session when the time cannot be refilled. Sessions are non-refundable and must be used within the posted validity window.

I confirm the information provided is accurate to the best of my knowledge. * I understand massage therapy is not a substitute for medical care. * I agree to the cancellation, late arrival, and no-show policies. * Signature (type full name) *