Intake Form for Massage and Lymph Drainage
Tessera Therapeutic Massage ~153 Elm St, Suite 1, Montpelier, VT 05602 ~ 617-447-3038
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First Name *
Last Name *
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Street Address *
Town/City *
State *
Zip Code *
Phone Number *
Date of Birth *
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Email Address *
Would you like to receive appointment confirmations and reminders via email or text (may select multiple)? *
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Would you like to receive newsletter via email (monthly)?
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Would you like to be notified of last minute appointment availability via email?
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Referred by
The following information will be used to help plan safe and effective sessions. It will be kept confidential. Please answer to the best of your knowledge.
Do you have any allergies or skin sensitivities to oils or lotions? *
If so, please explain
Do you have any particular goals or focus areas for this  session? *
If so, please list
Are you currently taking any medications or supplements? *
If so, please list/explain (or bring a list to your first appointment if extensive)
Please select any condition below that applies to you
Please explain any condition you checked above
Is there anything else about your health history that you think would be useful for your massage therapist to know?
Consent for Treatment
Because massage/manual lymph drainage 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 practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I further understand that massage and/or manual lymph drainage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician or another qualified medical professional for any mental or physical ailment of which I am aware.  If I experience pain or discomfort during treatment, I will immediately inform the practitioner, so the pressure can be adjusted to my level of comfort. I understand that it is within my right, as well as the right of the therapist to refuse receiving or facilitating treatment. I hereby give my consent to receive therapeutic non-sexual massage and/or manual lymph drainage at Tessera Therapeutic Massage and I understand that Tessera Therapeutic Massage and its practitioners are not responsible for any personal injury or loss of property.
Understanding all of this, I give my consent to receive care, by typing my name below. *
Acknowledgement of cancellation policy
In the past, failure to cancel prior to 12 hours before the start of the appointment time resulted in a charge of your full session fee if I was unable to fill the appointment slot. Exceptions to this have always been emergencies, illness, or difficult weather. Amid the ongoing uncertainty of COVID-19, I have modified my cancellation policy to offer greater flexibility to all clients. If you need to reschedule due to potential Covid exposure, quarantine, or if you are not feeling well, I understand and request for you to please contact me as soon as possible to reschedule. There will be no penalties for these cancellations. Appointment times are as scheduled - if you arrive late, your session may be shortened. You will be charged the full amount of the scheduled session. Please plan to arrive on time.
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