Name *

First Name

Last Name

Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Month and day of your birthday *

MM

DD

YYYY

Policy - Scheduling *

Please check that you have read and agree.

Scheduling - I understand that if I cancel or reschedule with less than 24 hour notice, I will be charged a 50% cancellation fee. I also agree that if I am late for my session, the session will still end at the originally scheduled time but full service fee will be charged.

Policy - Payments *

Please check that you have read and agree.

Payments - I understand that full payment is due at the time of service.I I understand that accepted forms of payment are cash, credit/debit card, and electronic payments (e.g., Venmo, PayPal) AND Health Savings Plan that use a “card” for payment. I understand Laura Wheeler does not direct bill insurances.

Policy - Illness *

Please check that you have read and agree.

Illness Policy: If you are feeling unwell (fever, cold, flu, COVID-19 symptoms), we ask that you reschedule your appointment to prevent the spread of illness. Rescheduling fees will be waived if rescheduled with more than 24 hours’ notice.

Policy - Professionalism *

Please check that you have read and agree.

Professionalism: Our massage therapists adhere to a strict code of professional ethics. We ask that all clients also maintain respectful behavior during their sessions. Any inappropriate behavior (sexual innuendos, sexual harassment, requests for sex or genitalia massage, “happy-endings”, etc.crude or sexually alluding comments will not be tolerated, even as a “joke”) will result in immediate termination of the session, and full payment will still be required.

Policy - Draping and Comfort *

Please check that you have read and agree.

Modesty and Comfort: Our therapists are trained to ensure your comfort and will always work to respect your boundaries. You will be properly draped during your massage, with only the area being worked on exposed. Please feel free to communicate with your therapist at any time if you are uncomfortable or would like adjustments to pressure, temperature, or music.

Policy - Disclosures *

Please check that you have read and agree.

Disclosures: Clients are encouraged to discuss any preferences or concerns with the therapist prior to the session (e.g., pressure, specific areas to focus on, allergies, etc.).

Policy - Confidentiality *

Please check that you have read and agree.

Client Confidentiality: All client information, including personal details and health history, is kept confidential and will never be shared without the client’s consent, except as required by law.

Policy - Accessability *

Please check that you have read and agree.

Accessibility: We are committed to making our services accessible to all clients. If you require special accommodations, such as wheelchair access or other support, please let us know in advance so that we can prepare appropriately.

Policy - Consent *

Please check that you have read and agree.

Consent: All clients must give informed consent to the massage therapy session before the treatment begins. You have the right to withdraw consent at any time during the session.

Policy - Right to Cancel *

Please check that you have read and agree.

Right to Cancel: Laura Wheeler, LMT and Grace Holistic Therapies, reserve the right to cancel any appointment or session in the event of an emergency, illness, or if the therapist is unavailable. In such cases, we will notify you as soon as possible and offer you an alternative date and time for your session.

18 or over / If Minor, Authorization of Guardian for the application of massage therapy. *

Please check the appropriate box

Client is a minor. As parent or legal guardian, I authorize Laura Wheeler lmt to provide massage therapy to said minor to promote wellness care.

I have fully read and understand this intake form and to the best of my ability have answered all questions truthfully for either myself or the minor of whom I have legal custody of.

Signature and Date *

By digitally signing below, you are authorizing Laura Wheeler, lmt to provide Massage Therapy to you. You are also releasing Laura Wheeler, lmt of any liability financial or else wise should and symptoms unknown or previously known be aggravated or inflamed. Massage is intended to be beneficial to the body ,mind and spirit. Although it is uncommon, there may be some brief discomfort, your massage session should not be painful. By signing this form you state that you will let Laura Wheeler, lmt know if any aspect of the massage causes discomfort or pain so that you may be properly adjusted, advised to stop pr guided according to your needs. You also state by signing this form that you have informed Laura Wheeler, lmt of any illnesses, diseases or conditions that would make this massage therapy session inappropriate for your health to your best knowledge.

First Name

Last Name

Date of Electronic Signature *

MM

DD

YYYY