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Thank you for choosing to save time by printing and filling out the required forms before your first Massage Therapy appointment with us!
Here is what you need to do:
Step 1: Print out the Health History, Policy Statement, and Informed Consent forms.
Step 2: Read over the forms carefully to make sure you understand them.
(if you have any questions, feel free to call/email us)
Step 3: Sign both the Informed Consent and Policy Statements (again making sure to read them carefully).
Step 4: Fill out and sign the Health History form. This step is very important as it will tell your therapist your medical background, which will help to better tailor the Massage session to your individual needs.
Step 5: Print out a copy of each form for your personal records (optional).
You will need to fill these forms out before your first appointment anyways, so we're glad that you're choosing to do it now.
Thanks again, and we look forward to seeing you!
Massage Redefined, LLC
Massage Therapy Health History Form
In order to maximize the effectiveness and safety of your massage therapy session(s), please take the time to carefully fill out this health questionnaire; your personal health history will be treated in a confidential manner. Your feedback is appreciated before, during, and at the end of the session(s) to help tailor the massage session and address your concerns in the best manner possible.
Client Information
Name:____________________________________________________________Phone: ( )_________-______________
Address:_______________________________________________________________________ Apt#:___________________
City:___________________________________________State:______________Zip:__________________________________
E-Mail:____________________________________________________________________ Date of Birth:_________________
Occupation:_______________________________________Referred by:___________________________________________
In case of emergency:_______________________________________________Phone: ( )_________-______________
Insurance Information (please ignore if you are not using a co-pay/deductible)
Insurance Carrier Name:______________________________________________________________________
Group Number:_____________________________________ Policy Number:____________________________
Phone Number of Insurance Company:______________________________Date of Birth:____________________
Address to mail claims:______________________________________________________________________
General & Medical Information:
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qYes qNo Have you ever had professional massage?
qYes qNo Are you under the care of a physician?
If so, for what reason(s)?_______________________________________
____________________________________________________________
qYes qNo Were you referred by someone?
If so, who?_____________________________
qYes qNo Are you currently taking any medications?
If so, Please list them:__________________________________________
____________________________________________________________
____________________________________________________________
Please circle the following option that best describes your expectations for the Massage Therapy session:
To completely relax, no issues in particular.
To relax with emphasis on a few trouble spots.
I have specific areas that need customized and focused work.
Circle your preferred pressure:
Light Pressure
Medium Pressure
Deep pressure
Are there any parts of your body you do NOT want massaged?__________
_____________________________________________________________
_____________________________________________________________ |
Paralysis? qYes qNo
Where_____________________________________________________
Numbness? qYes qNo
Where_____________________________________________________
Tingling? qYes qNo
Where_____________________________________________________
Allergies? qYes qNo
Type_______________________________________________________
Heart Condition? qYes qNo
Explain_____________________________________________________
Recent Surgeries? qYes qNo
When/Where________________________________________________
Cancer? qYes qNo
Location?___________________________________________________
Pregnancy? qYes qNo
What Trimester?_____________________________________________
Any Complications?__________________________________________ |
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Kidney Disorder? qYes qNo
Arteriosclerosis? qYes qNo
Sinusitis? qYes qNo
Headaches? qYes qNo
Sciatica? qYes qNo
Implants? qYes qNo
Varicose Veins? qYes qNo
High Blood Pressure? qYes qNo
Do you Wear Contacts? qYes qNo
HIV/AIDS? qYes qNo |
Liver Disorder? qYes qNo
Diabetes? qYes qNo
Arthritis? qYes qNo
Abdominal Pain? qYes qNo
Back pain? qYes qNo
Asthma? qYes qNo
Blood Clots? qYes qNo
Severe PMS? qYes qNo
Herniated Disk(s)? qYes qNo
Hypoglycemia? qYes qNo |
Hyperglycemia? qYes qNo
Swelling? qYes qNo
Bursitis? qYes qNo
Dizziness? qYes qNo
Chest Pain? qYes qNo
Neck Pain? qYes qNo
Skin Disorders? qYes qNo
Epilepsy? qYes qNo
TMJ? qYes qNo
Chronic Insomnia? qYes qNo
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Extra Comments or elaborations? Please Specify:_________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
PLEASE TAKE A MOMENT TO CAREFULLY READ THE FOLLOWING INFORMATION AND SIGN WHERE INDICATED.
(If you have a specific medical condition or specific symptoms, massage / bodywork may be contraindicated. A referral from your primary care provider may be required prior to massage services being provided.) If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage/bodywork should not be construed as a substitute for medical diagnosis or treatment and that I should consult a physician or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage/bodywork therapists 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 therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapists part should I neglect to do so. It is also understood that any illicit or sexually suggestive remarks or advances that I make will result in immediate termination of the session.
Participant
Signature:___________________________________________________________________ Date:___________________________________
Therapist
Signature:___________________________________________________________________ Date:___________________________________
Information and Suggestions for the Client
· Prior to your massage, remove all jewelry and pull long hair back with a clip.
· Because of the ability to easily access the body, the massage is given while you are disrobed. A top and bottom sheet will be provided for modesty and warmth.
· It is preferred that you still wear your bottom undergarments during your session.
· During your massage, please give your therapist feedback as to pressure (deeper or lighter) or point out painful or ticklish areas of your body.
· Feel free to ask your therapist any questions about their procedure. Your therapist is a highly trained professional and will be happy to make you feel well informed and comfortable.
Massage Redefined, LLC
Policy Statement
About Massage Therapy
The definition of Massage Therapy, as stated by the Laws of Florida pertaining to Massage Therapy is: "Massage" means the manipulation of the soft tissues of the human body with the hand, foot, arm, or elbow, whether or not such manipulation is aided by hydrotherapy, including colonic irrigation, or thermal therapy; any electrical or mechanical device; or the application to the human body of a chemical or herbal preparation.
The benefits of massage therapy include improved circulation, digestion and immune functions, flexibility, breathing, posture, and general health; reduction of stress and anxiety; increased clarity; increased energy; and a greater sense of the mind-body connection. Massage can make certain conditions worse, so please enlighten your therapist of any health problems.
About Us
Massage Redefined Therapists are Nationally Certified and Florida State Licensed; providing Integrated Hawaiian Massage, Chair Massage Events, as well as Reiki Energywork sessions. Massage Redefined, LLC is a member of the South Tampa Chamber of Commerce; they take great pride in being a professional member of the South Tampa community where they practice.
Massage Appointments
Massage and Reiki sessions range from ½ hour, 1 hour, to 1½ hour appointments. To make an appointment you may either call us or book online, your promotional code may be given through either way of scheduling. Massage sessions are by appointment only and all appointments will be confirmed the day before via phone call or email.
Payment will be rendered before the service and will be accepted in the form of cash or major credit cards. We currently accept Blue Cross Blue Shield Insurance at this time.
Should you need to cancel your appointment, please do so at least 24 hours' prior. If 24 hours notice is not given, you will be charged 50% of the service fee. If you are late for your appointment, please understand that you may not be able to receive a full session.
Referral System
At Massage Redefined, LLC we have a special Referral Network which allows you to share your wonderful Massage Therapy experiences with your friends, family, co-workers, or anyone who you think needs an Informative and Therapeutic awakening. If you refer someone that comes in and receives a session from us, you'll receive $10 off your next session for referring them, and they will also get $10 off their first session.
Massage Redefined, LLC "VIP Members"
Once you have referred 3 new people and have had 10 or more massage appointments at Massage Redefined, you will be upgraded to VIP status! This new status will automatically give you 10 dollars off all of your future Massage Therapy and Reiki appointments! Further upgrades in status will be determined at a later date.
Gift Certificates
Gift certificates will be signed and authorized by Massage Redefined personnel and will contain a specific number to validate the certificates authenticity. In order to be redeemed, the certificate must be physically presented at the time of the appointment. Gift certificates will not be redeemed unless for an appointment or for store credit which can be applied to services only at this time.
What to Expect
Please plan to arrive early for your first appointment so you can fill out and review the required health history form, sign our policy statement and informed consent forms, and then review these forms with your therapist. If you prefer, you may save time by printing the required forms from our website and fill them our prior to your appointment.
It is extremely important that thorough knowledge of your health history is obtained and discussed; massage can make certain conditions worse, so please enlighten your therapist of any health problems. Future massages after the initial visit will only take a few minutes to update the therapist should there be any changes.
You may dress however you wish, but if you would like to receive a massage following a workout, exercise, or any manual labor, please shower before your massage appointment.
The Massage Process
Upon discussion of your health history form and after the manner of draping has been explained, your comfort level of disrobing, and any other concerns you might have, your therapist will leave the room, allowing you to position yourself on the massage table in the appropriate way discussed before-hand.
Once you are disrobed, on the table, and under the sheets and blanket, they will knock to make sure you are ready, come back into the room, and begin the session.
There will be soothing music available for during the massage, however you have the right to customize your massage experience. During the massage session, please speak up if any of the techniques are not to your liking in any way and they will be changed.
When your session is complete, your therapist will again leave the room to allow you to get dressed.
All sessions will be completely confidential.
Thank you for choosing Massage Redefined for your Massage Experience in South Tampa!
(813) 831-9420
http://www.massageredefined.com/
sam@massageredefined.com
Signature of Participant:___________________________________ Date:____________
Informed Consent
Ø I understand that massage therapy and bodywork are for the purposes of stress reduction, relief from muscular tension and spasm, general relaxation, and improvement of circulation and energy flow.
Ø I understand that the bodywork practitioner does not diagnose illness, disease, or any other physical or mental disorder. The practitioner does not prescribe medical treatment or pharmaceuticals, nor does he/she perform any spinal manipulations.
Ø It has been made very clear that massage therapy and bodywork are not substitutes for medical examination or diagnosis and that it is recommended that I see a medical practitioner for any physical ailment that I may have.
Ø I have stated all of my known medical conditions on the Health History Form. I have consulted a medical doctor or licensed medical health care practitioner regarding these conditions.
Ø I realize it is solely my responsibility to keep the bodywork practitioner updated on any changes in my physical health and I understand that the practitioner shall not be liable should I fail to do so.
Ø I agree to actively participate, as much as possible, in my own healing and health maintenance.
Ø I understand that all massage therapy and bodywork offered is strictly non-sexual. If any sexual comment, suggestion, or advancement ensues, it shall result in immediate termination of the massage session.
Ø By signing this release, I hereby waive and release any and all liability, past, present, and future, relating to massage therapy and bodywork.
Ø I have received the policy statement, and have read and agree to the policies therein.
Signature:_____________________________________________ Date:_______________
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Redefining Massage Therapy, Reiki, and Reflexology in South Tampa
 Massage Redefined, LLC
3420 South Dale Mabry Highway
2nd Floor, entrance in rear of parking lot
South Tampa, Florida 33629
Phone: 813-831-9420
Email: Sam@massageredefined.com
Monday - Saturday 9am - 7pm
MM# 23019 - MA# 56213
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