Amara Massage Therapy & Wellness
Birthdate: Sex: Email:
Address: City: State: Zip:
*In addition to phone confirmation calls, would you like to receive texts?
*How often do you receive massage therapy?
*Are you currently experiencing pain?
If so, where?
*Do you have any recent injuries/surgeries your therapist may need to know about?
If yes, please describe
*Are you currently taking pain medication?
If pregnant, which trimester?
1st 2nd 3rd
Please indicate if any of the following apply to you
Items marked with an asterisk (*) indicate a partial or full massage contraindication. Please consult with your therapist to discuss how they may affect your massage therapy session.
According to what you’ve checked above, please provide further detail for any condition(s) below if necessary:
*How much pressure do you prefer during your massage?
*Tell us your preference toward pain during your session.
*Tell us what style of massage you would like to receive today
I want a full body Swedish Massage (Relaxation Massage)
I want as much of my body worked as possible with some time on trouble spots (Deep Tissue Massage)
I want a focused session, working only my trouble spots (Treatment Massage)
Based on your previous massage experiences, what are some things you liked, and also disliked, about your experiences?
Specialty Modalities & Enhanced Massage Disclosures
Amara Massage Therapy & Wellness offers massage to expectant mothers. We are well aware of the physical changes and challenges a woman’s body experiences during pregnancy and prenatal massage can be performed safely and effectively during all stages of a pregnancy to help the mother manage those changes and challenges. We encourage you to be as comfortable as possible, and bolstering/positioning can be customized. After careful review of all available evidence based massage resources, Amara has found pre-natal massage to be safe throughout pregnancy and can work on clients in any position, including prone/face down through the third trimester. However, there are conditions that may disqualify a mother from receiving massage. Those include:
- A diagnosis as a high-risk pregnancy by a physician.
- Preterm labor/possible miscarriage: discharge of blood, amniotic sac rupture, pains or contraction in uterus.
- Pre-eclampsia (toxemia): high blood pressure, protein in the urine, blurred vision, headache, nausea, swelling in the legs, and water retention.
- Gestational Diabetes: abnormal appetite/thirst, sugar in urine.
- Deep Vein Thrombosis (DVT): pain, redness, or swelling isolated to one leg
If you have one or more of these conditions, you may not be eligible to receive massage without physician approval. Please consult with your therapist to determine your eligibility. By signing this form you acknowledge that to the best of your knowledge and with your OB/GYN or Midwife counsel/approval you are approved to receive professional massage therapy serices.
Hot Stone Massage
The addition of Hot Stones as an enhancement to your massage can be a very relaxing experience. However the application of heat can be contraindicated for clients with the following conditions: Diabetes, cancer, autoimmune dysfunctions, epilepsy, neuropathy, heart disease, low blood pressure, skin conditions, recent surgeries, and pregnancy. If you have any of the above conditions, please consult with your therapist to determine your eligibility.
Silicone Massage Cupping Tools
With your consent, select therapists at Amara may elect to add the use of silicone cups as a complimentary tool in your massage; much like they might use a hot stone or wooden bar. The silicone cups create a vacuum or suction on the skin. This vacuum may produce a reaction/discoloration of the skin and although we don't consider this discoloration to be harmful we do want to make sure clients understand the possibility of marks on their skin. These marks are more likely to occur with "static cupping" (where a silicone cup is left stationary for a period of time.) For this reason our therapists integrate "dynamic/sliding cupping" (where a silicone cup is moved over the skin as an extension of the hands) to decrease the possibility of marks.
At AMT&W we focus on using cups strictly as a massage tool to create different sensations in the tissues. We do not use cupping to move "energy" or illicit detoxification as there is no evidence based research indicating that cupping or massage therapy causes any sort of detoxification. Like all AMT&W modalities and service offerings, we encourage you to maintain open communication with your therapist about your comfort and consent of a certain tool or modality. Silicone massage cups should not be used with some skin and health conditions. Always inform your therapist of changes in your health history to ensure we are offering you the safest session possible.
I understand that my therapist may integrate cupping therapy, hot stone therapy or pre-natal massage techniques based on my preferences and requests. I have fully read and clearly understand the AMT&W Specialty Modalities & Enhanced Massage Therapy Disclosure.
BUSINESS POLICIES/INFORMED CONSENT - PLEASE READ CAREFULLY
Therapist Training and Experience/Limitations of Massage Therapy
All of the massage therapists working at Amara have completed a minimum of 500 hours of massage training from a state-approved school and passed the state licensing requirements. Therapists at Amara are knowledgeable in Swedish massage, deep-tissue and myofascial techniques. We also have therapists who specialize in prenatal massage and Thai massage (this style includes heat packs, stretching and light compression). Pick up a menu of services from our front desk to learn more about these forms of bodywork. Please visit our website to see a list of our preferred local providers that we refer to in the event we can’t meet your particular needs. Massage therapists do not diagnose medical diseases or musculoskeletal conditions. Massage therapy is not a substitute for medical examination and or treatment. Massage therapists do not prescribe herbs or drugs, including aspirin or ibuprofen, or medical treatments. They do not perform spinal adjustments and they cannot counsel clients about emotional or spiritual issues as would be provided by a mental health professional or spiritual leader. If you experience symptoms that lead you to believe you may have a medical condition, it is recommended that you visit a physician for diagnosis and treatment.
Expectations and Rights
The client is expected to demonstrate good hygiene and not use illegal drugs or alcohol before the session (the use of drugs and alcohol make it unsafe for a client to receive massage). Clients and therapists are expected to refrain from any behavior of a sexual nature, including sexual jokes, nicknames, or immodest conduct. Sexual behavior from the therapist toward a client is grounds for therapist termination and may lead to a formal complaint filed with the state board of massage. This may lead to the loss of the therapist’s license. Sexual behavior from the client toward the therapist is inappropriate and will lead to the termination of the session and refusal of further service.
The client has a right to prompt, professional service in an environment that is clean, private, and safe. Client information is not shared with any members of the public or other health-care providers unless the client releases the information in writing. A court of law may order the client’s health-care records released to the court as part of a legal proceeding. Therapists are obligated to report information about the abuse of a child, elderly person, or mentally or physically challenged person in the event that such information is related during the session. Therapists are obligated to report threats of self-harm, or threats that the client plans to harm another person, to authorities. The client has the right to end the session at any time should they feel dissatisfied or uncomfortable with the session in any way. Clients who are dissatisfied with a therapist are encouraged to contact the clinic general manager. Formal complaints can be filed with the state on their website: https://www.colorado.gov/pacific/dora/Massage_Therapy
Your Massage Session and Adverse Massage Reactions
After you complete the health intake form, the therapist will take you to a private treatment room, review the form with you, and discuss your goals for the session. The therapist will customize the massage to meet your specific needs within the limits of his or her training and scope of practice. The therapist will then leave the room while you undress and position yourself under the drape on the massage table. Only the area being massaged at the time is undraped as the session proceeds. The breasts, genitals, and anus are never undraped during a session, and every effort is made to respect and protect both the client’s and therapist’s modesty. You may leave on your underclothing if you prefer. While the therapist will ask you a few questions—for instance, about the comfort of the stroke pressure, room temperature, or choice of session music—and you should let the therapist know immediately if you are not comfortable, other conversation during the session is generally discouraged. Silence allows you to relax fully and enjoy the session.
Massage may lead to adverse reactions in certain situations or when used with certain conditions or medications. The massage therapist will evaluate your health-history intake and ask you questions to make sure it is safe for you to receive massage. In the event the massage therapist is uncertain that massage will be of benefit to you, he or she may ask you to provide a note from your physician stating that it is safe for you to receive massage. Please provide complete details of medical conditions and medications to your massage therapist during the health-intake interview. Failure to inform the massage therapist of all medical conditions and medications may place you at increased risk for adverse reactions.
Business Policies and Practices- 24 HOUR CANCELLATION POLICY!
You may book a 30, 60 or 90 minute massage session. Amara accepts cash, personal checks, and all major credit cards and does require that all guests have a valid/current Credit Card on file for late cancellations. We do not bill insurance companies for services. For new guests needing to complete health form/consent at the center, plan to arrive at least 20 minutes before your start time. Guests who are already in the system should plan on arriving at least 5 minutes before for all recurring appointments to ensure a full 30, 60 or 90 minutes of hands on time. The first session usually requires a slightly longer intake process, so new clients please share on this form any special requests, likes/dislikes, etc. to expedite your first service. Clients arriving late will still be charged for the full session time booked and the session will end promptly at the scheduled time. Clients must cancel sessions with 24 hours notice or pay the $40 late cancellation fee, appointments cancelled within 3 hours will be charged the full cost of the session. Returned checks will be charged a $20 processing fee. Business hours are Monday 10:00-7:00, Tuesday-Friday 8:30-8:00, Saturday 9:30-3:30. Walk-in appointments are accepted if therapists are available. We are located in downtown Fort Collins, an urban environment, please allow extra time to find parking and get settled so you are not rushed. Children and teens are welcome, but an adult guardian must be present with those under the age of 15 in the treatment room through out the session. A tip to the therapist for exceptional service is optional, but appreciated.
I, , have read and clearly understand the attached BUSINESS POLICIES/INFORMED CONSENT detailed by Amara Massage Therapy & Wellness, and I would like to receive a massage session or request a session for my child or dependent. I understand that a copy of these policies is available to me at any time by request and also located on the Amara website. I understand the benefits and limits of massage therapy and understand massage may cause adverse reactions in certain situations. If I experience any discomfort during the session, I will immediately inform my therapist so he or she can modify the massage strokes. I understand massage therapists do not diagnose diseases or conditions, prescribe medications or treatments, or perform spinal adjustments. I recognize massage is not a substitute for medical treatment and should I need medical treatment, I will seek out the appropriate health-care professional (physician, psychotherapist, chiropractor, etc.). I understand that it is my responsibility to keep the massage therapist informed of changes in my (or my child’s or dependent’s) health status, diagnosed medical conditions, and medication. I understand that failure to inform the therapist of these changes may place me (or my child or dependent) at greater risk of adverse reactions to massage. I release the massage therapist of any liability if I fail to disclose the appropriate health-related information. I understand that in order to book appointments at Amara I need a valid/current credit card stored on my client profile. I understand that the credit card on my profile will only be charged in the event of a no show or late cancel or if I sign up for an annual membership. I understand Amara charges a $40 fee for cancelling within 24 hours and charges full price for sessions cancelled within 3 hours or if I no call/no show. I understand that Amara is a center focused on THERAPEUTIC MASSAGE ONLY! Any sexual advances, innuendo or inappropriate touch is EXPRESSLY FORBIDDEN!