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Let’s Get Started with Your Massage Therapy Journey

Please fill out the form below 👇 to help us understand your wellness goals, physical concerns, and massage therapy preferences. Your responses will help us personalize your session to better suit your unique needs and ensure a relaxing, comfortable experience.

CLIENT INFORMATION

Name

Phone *

Email *

Address

Street Address

State

City

Zip:

Date of birth

Emergency Contact Name:

Relationship:

Date:

Occupation:

How did you hear about us?

Are you currently under the care of a physician?

Yes

No

If yes, please list:

Do you have any mobility limitations?

Yes

No

If yes, please describe:

HEALTH HISTORY & CONCERNS

Are you currently taking any medications?

Yes

No

If yes, please list :

Any allergies? (oils, lotions, nuts, fruits, etc.)

Yes

No

If yes please list

Are you pregnant?

Yes

No

If yes, how many months?

Are you currently under medical supervision or receiving other medical interventions?

Yes

No

If yes, please describe :

MUSCLE / PAIN ASSESSMENT

Please describe the location, type and intensity of pain (1–10):

SOAP NOTE – MASSAGE THERAPY

S – SUBJECTIVE

Client's Report

Please describe your symptoms, pain level, condition and goals for treatment.

Pain Level (0–10):

O – OBJECTIVE

Assessment

Observations and findings during the session (posture, range of motion, area of tension, etc.).

ROM (if applicable):

Improved

Decreased

No Change

A – ASSESSMENT

Clinical Impression

Muscle imbalances, restrictions, progress and response to treatment.

Plan Continuation:

Yes

No

Frequency:

P – PLAN

Treatment Plan

Next session focus and recommendations.

Home Care Instructions:

LIRA CLINICAL SKINCARE PRODUCT CHECKLIST

For After Massage Treatment / Homecare

Recommended for optimal skin health and results.

CLEANSE :

Lira Clinical Bio-Barrier Cleanser

Lira Clinical Ultra Cleanser

Lira Clinical Gel Cleanser

Lira Clinical Acne Cleanser

Lira Clinical Retinol Cleanser

Lira Clinical Pro A Corrective Moisturizer

Lira Clinical Ultra Hydrating Cream

Lira Clinical Clear Skin Moisturizer

Lira Clinical Barrier Repair Cream

Homecare Instructions:

RELEASE FOR VIDEO / SOCIAL MEDIA

I hereby grant permission to Mind Beauty Body Skincare to take photos and/or videos of me during my treatment for educational, promotional and social media purposes (e.g., Instagram, Facebook, website, ads).

I give my consent.

I do not give my consent.

I understand that no identifying information will be shared without my written permission.

Signature:

Date:

LEGAL VERBIAGE & CLIENT ACKNOWLEDGEMENT

I understand that massage therapy is a therapeutic service and not a substitute for medical care. I agree to inform my therapist of any changes in my health, including new medications, medical conditions, or injuries. I release Mind Beauty Body Skincare, its practitioners and staff from any liability related to massage therapy services, except in the case of gross negligence. I have read and agree to the above information and certify that it is true and complete to the best of my knowledge.

Client Signature:

Date: