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
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.
Specialty Modalities & Enhanced Massage Disclosure Acknowledgement
I understand that my therapist may integrate cupping therapy, hot stone therapy or pre-natal massage techniques based on my preferences and requests. I consent and have fully read and clearly understand the AMT&W Specialty Modalities & Enhanced Massage Therapy Disclosure.
INFORMED CONSENT AGREEMENT
We are a center focused on THERAPEUTIC MASSAGE ONLY! Any sexual advances, innuendo or inappropriate touch towards a practitioner or staff member is EXPRESSLY FORBIDDEN!
I understand that the massage therapist is not a physician and cannot provide a medical diagnosis.
We do not bill insurance. All payments are due at the time of service, no exceptions.
By signing below I certify that the information I have provided is correct and up-to-date and that I am responsible for informing Amara Massage Therapy & Wellness of any changes in my contact information or medical status.
I hereby consent to receive therapeutic massage services provided by Amara Massage Therapy & Wellness and I certify that I have read and understand the above policies and agree to abide by them.
We require 24 hours notice for all cancellations, all appointments cancelled within 24 hours are subject to a $35 late cancellation fee. Clients who cancel within 30 minutes of their appointment or who no show for an appointment will be charged 100% of the service cost. In the event of a late cancellation or no show, the amount will be collected by charging the credit card on your account profile. Our therapists work very hard, and each appointment represents a significant portion of their income. Late cancellation/no show fees ensure that your therapist is still reimbursed for their time and availability. Thank you in advance for respecting our time and schedule!