Lunova Soma Intake Form

To ensure you receive the most effective and personalized massage experience, please complete this intake form thoroughly prior to your appointment. The information you provide will help us understand your health history, preferences, and goals.

First name

Last name

Phone Number

Please provide a phone number that can receive texts.

Date of Birth

Month

Day

Year

Occupation

Employer

Primary Care Physician

Primary Care Physician Contact Number

Emergency Contact Name

Emergency Contact Phone Number

Are you taking any prescribed medication?

Yes

If yes, please list below

Are you currently pregnant?

Yes

If yes, how far along is your pregnancy?

Not Applicable

First Trimester

Second Trimester

Third Trimester

If you are not past your first trimester, please consult your OBGYN or Primary Care Physician prior to booking an appointment. A doctor's note will be required if you indicate you are a high-risk pregnancy or if you are in your first trimester.

I agree to the above requirements in regards to my pregnancy, if applicable.

Are you currently diagnosed with cancer?

Yes

If yes, were lymph nodes removed?

Yes

If yes, are you currently undergoing treatment?

Yes

If yes, please describe your ongoing treatment

Cancer Diagnosis

Important Notice Regarding Massage Therapy and Cancer History

Massage therapy can affect the lymphatic system and may influence the progression of cancer. If you have had lymph nodes removed or are currently undergoing chemotherapy, it's essential to consult with your healthcare provider before receiving massage therapy. Massage should only be performed by a certified oncology massage therapist who has specialized training in safely adapting techniques for individuals with cancer.

Oncology massage therapists are trained to modify massage techniques to accommodate specific medical conditions and treatments, ensuring safety and comfort. They are knowledgeable about areas to avoid, appropriate pressure levels, and how to support the body during and after cancer treatments.

If you have had lymph nodes removed or are undergoing chemotherapy, please inform your massage therapist. This information will help them provide the most appropriate and safe massage experience tailored to your needs.

Your health and well-being are our top priority. Please consult with your healthcare provider and ensure that any massage therapist you see has the appropriate oncology training.

I consent to the above, if applicable

Do you suffer from chronic pain?

Yes

If yes, please explain

If yes, what makes it better or worse?

Have you had any orthopedic injuries?

Yes

If yes, please list and include general dates of injuries

Explain any condition you have marked above

Please list any other conditions/diagnoses you may have

Have you had a professional massage before?

Yes

Do you have any allergies or sensitivities?

Yes

If yes, please explain

Please describe your goals and expectations for this session

Lunova's Cancellation Policy

We ask that you please reschedule or cancel at least 1 day before the beginning of your appointment, or you may be charged the full price of your session.

Please reschedule or cancel at least 24 hours before the beginning of your appointment, or you may be charged a cancellation fee of 100% of the price of your scheduled appointment. I agree to be courteous and give at least 24 hours' notice to cancel or reschedule an appointment. Cancellation of the appointment less than 24 hours will result in a 100% charge of the total service. No shows will result in a charge of 100% of the total service and require pre-payment upon next booking. By booking this appointment, you agree to the cancellation policies. Please be considerate and stay home if you are sick or are experiencing any visible symptoms. You will be sent home and charged the cancellation fee

I've read and agree to Lunova's cancellation policy

Right to Refuse Service

We are committed to providing a safe and therapeutic environment for all our clients. To ensure the well-being of both clients and therapists, we reserve the right to decline or discontinue services based on various factors. This may include, but is not limited to:

- Unresolved or undisclosed health conditions

- Presence of contagious illnesses or open wounds

- Inappropriate or disruptive behavior

- Substance impairment (e.g., alcohol or drugs)

- Requests outside the scope of professional practice

- Scheduling conflicts or last-minute requests

We appreciate your understanding and cooperation in maintaining a respectful and health-conscious environment. If you have any questions or concerns about this policy, please feel free to discuss them with your therapist.

I've read and agree to Lunova's right to refuse policy

Opt-In to Receive Text Messages

Yes, subscribe me to receive texts related to my appointments, events, promotions and marketing by Lunova Soma.

By signing below I agree all information above is true

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