NEW CLIENT INTAKE FORM

Please fill out the following form.

First name

Last name

Phone

Age

Is this your 1st Massage or Lymphatic Session?

Yes

Are you suffering from a underlying medical condition, illness or injury?

Yes

If you answered yes to any of the questions above, please supply additional information. (i.e, cancer, Lupus, etc.)

Recent Cosmetic | Plastic Surgery?

Yes

I currently have drains

Name of yours surgeon and surgery center location *N/A if this does not apply.

Surgery Date

Día

Mes

Año

List surgeries (i.e. neck, back, hip, liposucion, tummy tuck, BBL, breast, etc). Otherwise say *NONE

List Medications you are currently taking or type *NONE

Medical complications before, during or after surgery (i.e. given blood, hemoglobin low, etc. ) Type *NONE if you had no complications.

📝 Combined Disclaimer and Waiver of Liability

1. Massage Therapy Disclaimer

I understand that massage therapy provided by Sharon Sterling and 1 Massage at aTime LLC is intended to promote relaxation, relieve muscular tension, improve circulation, and offer general wellness support. I acknowledge that:

Do not diagnose illness, disease, or physical or mental disorder.
Is not a substitute for medical examination, diagnosis, or treatment.
It is my responsibility to consult with a physician regarding any medical conditions.
I will inform the therapist of any known medical conditions, recent surgeries, injuries, or changes in my health status prior to each session.
I consent to appropriate draping and understand I may discontinue treatment at any time.

2. Post-Surgical Recovery & Lymphatic Drainage Disclaimer

I understand that post-surgical lymphatic drainage therapy, body sculpting, or recovery services:

Are non-medical, complementary wellness services intended to support the body's natural healing process following surgery.
Are not a replacement for medical or surgical aftercare, or a guarantee of results.
A consent form may be requested by therapist if needed.
May involve areas that are tender or healing, and I will communicate any pain, discomfort, or concerns immediately.
Require open communication regarding drains, incisions, medication use, and the presence of fluid collections such as seromas or hematomas.

I understand that results vary depending on individual healing responses, surgical techniques, aftercare practices, and lifestyle factors.

3. Waiver of Liability

By signing this document, I voluntarily agree to the following:

I release and hold harmless Sharon Sterling, 1 Massage at aTime LLC, its employees, agents, and contractors from any and all liability, claims, or demands related to the services provided.
I accept full responsibility for my participation in any service provided and acknowledge I am receiving these services of my own free will.
I affirm that all medical information I have provided is accurate and complete to the best of my knowledge.
I understand the risks involved, including but not limited to bruising, sensitivity, swelling, discomfort, or exacerbation of undiagnosed conditions.
I will seek immediate medical attention if I notice signs of infection, excessive swelling, fever, or any abnormal symptoms following treatment.

✅ Client Acknowledgement

I have read and understand the information provided above. I have had the opportunity to ask questions, and all questions have been answered to my satisfaction. I consent to receive massage therapy, post-surgical recovery care, and/or lymphatic drainage services under the terms outlined in this agreement.

Initials

If you have symptoms such as: fever, experiencing chills, headaches, nausea, faint, still draining after surgery (from your incisions) I am unable to see you until all symptomes have resolved. *If you still have your drains in but no symptoms, you can bee seen.

Additional guidance (337) 302-0877. NOTE: Wear your faja, and all inserts as recommended) Bring your post-surgery discharge instuctions)

Initials

I declare that the info I’ve provided is accurate and complete.

Cancellations must be made 48 hours before the reserved appointment time, and 24 hours before to avoid fee charges. By signing this document, I (you) understand that any illicit or sexually suggestive remarks or advances will result in immediate termination of the session. I (you) affirm that all information provided above is correct to the best of my knowledge.