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Informed Consent & Health Information

I understand that the services provided consist of non sexual therapeutic massage and bodywork. Planet Massage reserves the right to terminate a treatment at any time for any reason without compensation including inappropriate behavior.

Your licensed massage therapist cannot, and will not provide any formal or implied diagnoses or perform medical treatments for which they are not qualified. I understand that it is my responsibility to seek qualified medical advice where necessary and/or provide Planet Massage and your therapist with a physician’s prescription as required by any condition or disease that may affect your treatment today or in the future. I have informed the therapist of medications I am taking, and all of my known physical & medical conditions and will keep them updated on any changes as they occur in the future. I understand that there shall be no liability on Planet Massage or the practitioner due to omission of any of my health or medication history whether known or unknown at the time of treatment. Your therapist is an independently licensed professional, and is responsible for his/her therapeutic services. I understand that sometimes a single session may not bring chronic pain to an immediate halt. A series of treatments is often necessary to obtain desired outcomes. The approach may be adjusted as time goes on. In a small number of cases, discomfort may be exasperated after a treatment it as new lavers of tissue might present themselves as needing attention. It is possible you may experience soreness or redness after massage which generally lasts no more than a few days with some modalities. If residual soreness lasts more than a few days it's always a good idea to check with a doctor for further examination to eliminate the possibility indicative of a more serious condition. Some modalities including but not limited to Connective Tissue Massage and Structural Integration may result in visible marks or redness which generally goes away within a couple of days, but occasionally takes longer depending on your own bodies responses.  I have notified the therapist if I have any skin sensitivities or nut allergies. Some of our oils and lotions may contain nut products. Skin sensitive and nut free lotions are available, please ask. Should I experience any discomfort, pain or desire to change the pressure or techniques during the session, I will immediately communicate with the therapist so the treatment can be adjusted.

I Agree

Gratuities: Customary spa gratuities have typically not been included in your base service price. The exception may be for events, groups, discounted services, same day/rush services, special priced services or VIP special requests. A 20% service fee/gratuity may be added at the discretion of Planet Massage with your approval. At your discretion, you may increase gratuity for exemplary service.

Please Secure Your Valuables and remember to take them with you when you leave: Planet Massage is not responsible for your personal property and valuables anywhere on our property. Please be sure to double check and take everything with you upon leaving. Found items will be held for 30 days before discarding.

Payment is due in full when services are rendered; cash and credit cards are accepted. I agree to pay any credit card charges in accordance with my credit card agreement. I agree that Planet Massage may charge any credit card used for payment/ deposit for future appointments/deposits as agreed and outlined in our cancellation policy. Refund Policy. No refunds are offered once the appointment or training has been scheduled. All sales are final with no refunds offered.

I Agree
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Current Cancellation policy: Can be found at http://planetmassage.com/cancellation_policy/ and is subject to change at any time. A summary of the policy is as follows:

Cancelling or rescheduling prior to 48 hours: no charge and generally refundable with exceptions of special events, groups, or special peek times or holidays.  Special event, discounted services as well as weekend, holiday, evening or peak times may require a nonrefundable payment, nonrefundable deposit or stricter time limits may apply.

Cancelling or Rescheduling within 48 hours to 4 Hours:  50% of the appointment fee will be due unless we can reschedule your appointment, and rebook your reserved time. This may be waived at the sole discretion of Planet Massage if we can rebook the time slot and you reschedule. 

Cancelling with Less than 4 hours and No Shows: 100% payment for no shows & cancellation with less than 4 hours notice. Acceptations may be made at our discretion provided we can reschedule you, and rebook your reserved time.

Arrival Time and Late Arrivals:  For maximum “table time” and relaxation, please observe the following appointment arrival time guidelines: New clients, please arrive 10 minutes prior to your scheduled appointment time as to relax and consult with your therapist. If filling out health history, please arrive 15 minutes early. Established clients should arrive 5 minutes early. Planet Massage strives to run "on time" in consideration of our clients, therapists and associates. 95% of the time we are on time.  Our goal is to begin your massage at your scheduled time. We regret that we can not extend your appointment time for late arrivals. Please  confirm directions to our location in advance and plan accordingly.

I agree to the cancellation policy. ( If you are concerned about making your appointment or rescheduling, please contact Planet Massage and we will be delighted to work with you to find an preferable solution.)

I Agree

A standard full body massage often includes work on the gluteal muscles (the buttocks). Pain felt in the back, knees or elsewhere, including sciatic pains is often the result of hip, leg or glute tightness. Releasing this tightness often increases the success of the overall treatment. I consent to gluteal massage unless indicated in my preferences. ( You'll be given a chance in a minute to choose preferences) I agree to discuss any unanswered questions or concerns with my therapist prior to treatment.

I Agree

Directions: Directions can be obtained by visiting http://planetmassage.com/contact or by calling the day prior to your appointment. Google generally routes you well, but we also offer directions from many local areas with "locals Knowledge" included. Never rely solely on any online maps, your GPS or your navigation system. Planet Massage can not be responsible for navigational errors.

 

First Clients Name

First Name*

Last Name*

Phone*
First Clients Date of Birth*
First Clients Signature*
Second Clients Name

First Name*

Last Name*
Second Clients Date of Birth*
Third Clients Name

First Name*

Last Name*
Third Clients Date of Birth*
Fourth Clients Name

First Name*

Last Name*
Fourth Clients Date of Birth*
Fifth Clients Name

First Name*

Last Name*
Fifth Clients Date of Birth*
Sixth Clients Name

First Name*

Last Name*
Sixth Clients Date of Birth*
Seventh Clients Name

First Name*

Last Name*
Seventh Clients Date of Birth*
Eighth Clients Name

First Name*

Last Name*
Eighth Clients Date of Birth*
Ninth Clients Name

First Name*

Last Name*
Ninth Clients Date of Birth*
Tenth Clients Name

First Name*

Last Name*
Tenth Clients Date of Birth*
Clients Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Yes! I'd like to be part of the Prefered Customer Program for wellness tips & special offers from Planet Massage. (Max 5 per month)
Treatment Preferences & General Questions

What is your primary goal of your session today and how can we help you? *
My primary reason for today's treatment is*
To relax or combat stress
To treat a specific pain or condition
Maintain health/ preventative
A full body massage/just because/feels good
Other, please explain
Desired Pressure For Massage*
I'd like to discuss with my therapist
Light/Soft
Medium
Firm
Deep
Extra Deep ( Additional $10 fee)
I'm not sure/ I don't know

I like/want this part of my body to be worked on:

I DO NOT like/want this part of my body worked on. Please explain as necessary. Your therapist is available to discuss options or alternatives.
I would like to discuss long term solutions to wellness, pain relief, or stress relief with my therapist, owner or a master therapist
No Thanks
I'd like to Discuss with my therapist
Have the owner, clinical director or master therapist contact me

How did you hear About Planet Massage? Were you refereed? By Whom?

Do you have any other preferences for today's treatment? IE: Music, silence or style/modality if available?

Would you like to begin working on long term wellness goals with today's treatment? If so, how?
Medical History
Please check all that apply and give detail
Pregnant
Chronic Pain
Back Or Disk Injuries
Lack of flexibility- ROM
Muscle tightness
Headaches
Stress
Depression
Recent Surguries
High Blood Pressure
Low Blood Pressure
TMJ/Jaw Pain
Seisures
Pacemaker
Insomnia
Heart Condition
HIV/Aids
Skin Condition
Cancer/Tumors
Fatigue
Sprains or Strains
Arthritis (list type or types below)
Bone Condition
Foot Pain
Neck Injury
Head Injury
Other

Please Explain in Detail Any Checked Items
Are you currently seeing a *
Not seeing any doctor or therapist of any type
Doctor
Osteopath
Chiroprator
Physical Therapist
Massage Therapist
Other Therapist

Are you being treated for any health condition, if so, what?

Please list any accidents, injuries and surgeries.

Please list all current medications and what they are treating
Lifestyle Questioner To Assist Us In Providing The Best Possible Service & Results

List sports played and frequency. Do you work out? Please describe workout/fitness routine and frequency

Occupation ( Many occupations add to pain and stress in very specific ways)

Activities or lifestyle considerations which may effect your treatment today

Have you ever received a professional massage. If so, how long ago? Frequency? *

If yes, was your experience positive? Would you consider your results positive?

Is there anything else you'd like to discuss with your therapist?
Add-on's to enhance your experience today (May require advanced notice, call for availability)
Massage & Bodywork Extras & Enhancements: Note, PLEASE CALL in advance as availability is limited to schedule and therapist *
None
Upgrade to an Advanced Trained Therapist. Add $10 per hour (Generally 5+ years experience and a higher level of training in advanced modalities
Upgrade to Master Therapist $20 per hour ( Generally 10+ years experience and advanced training in multiple modalities for outstanding outcomes
Aromatherapy $10
Warm River Rocks Enhancement $19 Per Person
Steamy Hot Pack Back Treatment $10
Eucalyptus Warm Back Compress $15
Ice Therapy - Cryomassage includes Biofreeze (great for spasms, sever pain, injuries) $20
Bio-freeze Pain Relief Spray $5
Warm Towel Rub $10 (With or without aromatherapy)
Power Nap: Reserve the room for a 20 minute nap after your massage. Includes wake up with invigorating aromatherapy. $25 pp
Deluxe Power Nap: Reserve the Room for 20 minute nap, and wake up to rejuvenating aromatherapy and 10 minutes of foot massage or head massage $40pp
Massage Cupping $20
Chi Machine included in your massage $10
Chi Machine (Add 15 minutes) $25
Add Active Isolated Stretching Enhancement or Assisted Stretching ( Based on Therapist) $15 PP
Infra Red Sauna: Before or after your massage. 30 minutes, based on availability $29 PP
Optional: A few "deeper" questions for those interested in working with Planet Massage to help achieve long term wellness though massage, bodywork and wellness coaching.

What do you feel is the root cause of your pain, stress or condition?

What do you feel could best be done to improve this condition
How committed are you to making change to improve your health?*
N/A
Extremely. I'll do what it takes.
Serious and planning on it.
Serious. I'm willing, but lack a plan, or resources.
Planning on it.
Thinking about it.
Kinda, maybe.
Possible.
I'm not.
I'd prefer not to be healthy, happy or help my conditions.

What obstacles are standing in the way of implementing a plan for health, wellness or treatment?
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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