Lavelle Health — Massage Therapy intake & consent

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About you

Please answer as accurately as you can. Some questions are included to help Rae decide whether treatment should be modified, delayed, or cleared by a medical provider.

Full name *

Preferred name

Optional — what you’d like Rae to call you.

Are you 18 or older? *

YesNo

Parent / legal guardian name *

Guardian’s relationship to the client *

Email *

Your copy of this form will be sent here.

Phone *

Date of birth

Optional — helps Rae keep accurate records.

Home address

Emergency contact — name

Emergency contact — phone

How did you hear about Rae?

Your visit

What brings you in? *

Choose everything that applies.

Relaxation & stress reliefMuscle tension or tightnessAches or painInjury recovery or rehabilitationHeadachesImproved mobility or range of motionSomething else

Tell us a little more

Are there particular areas you’d like Rae to focus on?

For example neck and shoulders, lower back, legs.

Any areas you’d prefer she avoid?

What pressure do you generally prefer? *

Rae will always check in and adjust during your session.

LightMediumFirm / deepNot sure — let’s discuss

Have you had a professional massage before? *

YesNo

Is there anything Rae should know to make your appointment safer or more comfortable?

Health screening

Massage is generally very safe, but a few conditions need extra care — or a doctor’s okay — first. Please answer honestly: a “Yes” doesn’t necessarily mean you can’t receive treatment, it just tells Rae what to take into account.

Do you currently have a fever, an infection, a contagious illness, or feel generally unwell? *

YesNo

Please give a few details

Are you currently pregnant? *

YesNo

How far along are you?

Do you have any recent injuries, fractures, sprains, or strains? *

YesNo

What, and when?

Have you had surgery in the last 3 months? *

YesNo

What surgery, and when?

Any history of blood clots, DVT, stroke, or a clotting disorder? *

YesNo

Please give a few details

Do you have a heart condition, or high or low blood pressure? *

YesNo

Please give a few details

Do you have osteoporosis or any other bone-density or bone condition? *

YesNo

Please give a few details

Do you have varicose veins? *

YesNo

Whereabouts?

Any areas of numbness, tingling, or altered sensation? *

YesNo

Whereabouts?

Any skin conditions, rashes, open wounds, or anything contagious at the moment? *

YesNo

Please give a few details

Are you currently being treated for cancer, or do you have a history of cancer? *

YesNo

Please give a few details

Are you taking blood thinners or any medication that increases bleeding or bruising? *

YesNo

Which one(s)?

Any other medical conditions, or recent changes in your health? *

YesNo

Please give a few details

Current medications (if any)

Please mention blood thinners especially.

Allergies or sensitivities (if any), including to oils, lotions, scents, adhesives, or latex

Consent

Massage at Lavelle Health is a hands-on wellness service to help you relax, ease tension, and support recovery. Your practitioner is Raegan Brumer, RMT — “Rae” throughout this form. Sessions take place at Rae’s home studio. Please review each item carefully. These acknowledgements help confirm that you understand the nature and limits of the service before your appointment.

Your agreement is with Raegan Brumer

These services are provided by Raegan Brumer, operating as Lavelle Health. Throughout this form and the payment terms, “Lavelle Health” means Raegan Brumer.

I am the parent or legal guardian of this client, and I consent to this assessment and treatment on their behalf. I am signing on their behalf below. *

I understand that massage and related wellness services are not a substitute for medical diagnosis, medical treatment, emergency care, or advice from a physician or regulated healthcare provider. *

I confirm that the information I have provided is accurate and complete to the best of my knowledge. *

I agree to inform Rae of any significant changes to my health, medications, surgery status, pregnancy status, or medical condition before future appointments. *

I understand that Rae may refuse, modify, postpone, or discontinue treatment if she believes treatment may be unsafe, inappropriate, outside her scope, or if medical clearance may be required. *

I understand that certain medical conditions may require physician clearance before treatment can proceed. *

I understand that results are not guaranteed. *

I understand I can speak up about pressure or comfort at any time, and that I can ask to adjust, pause, or stop my session at any time, for any reason. *

I understand that I will be appropriately draped throughout the session, that the treatment is professional and therapeutic in nature, and that any inappropriate conduct will end the session immediately. *

I understand that treatment may include the gluteal area or other sensitive areas where clinically appropriate. I will remain appropriately draped, my consent will be confirmed before any such work begins, and I may decline or stop at any time. *

I consent to receiving massage from Raegan Brumer, RMT (“Rae”). *

I understand that payment is due upon receipt, and I have read and agree to the payment terms. *

Read the full payment terms →

I consent to Lavelle Health collecting, using, storing, and retaining my personal and health information for intake, treatment planning, scheduling, communication, invoicing, recordkeeping, and related client-service purposes. *

Your information is used to provide services and maintain client records — including emailing your completed form to you and to Rae. It is not shared except where required by law, required for safety, or authorized by you.

May Rae also keep an electronic copy of this form on file? *

Printed copies are kept with her client records either way.

Yes — keep my record stored electronically.No — keep printed copies only. The online record is removed automatically after 30 days (long enough to print it).

Acknowledgement & release

I understand that massage is a wellness service. I acknowledge that treatment decisions are based on the information I provide. I understand that withholding medical information, providing inaccurate information, failing to follow medical advice, or failing to update Rae about changes to my health may increase the risk of an adverse outcome. I release Lavelle Health and its practitioners from liability arising from undisclosed medical conditions, inaccurate or incomplete information, or my failure to follow medical advice or recommendations.

Signature

Typing your name below signs this form electronically: it confirms you filled it in yourself and agree to the statements above. If the client is under 18, a parent or guardian must complete and sign it.

Type your full name to sign *

Today’s date, recorded with your submission: August 9, 2026

Your intake is sent to Raegan Brumer, operating as Lavelle Health, and used for client records, appointment administration, care-related communication, and payment/insurance documentation where applicable. Information is not sold or used for marketing. It may be shared only with service providers or others where needed, authorized, or required by law.

This form is not monitored for emergencies. If you are experiencing chest pain, shortness of breath, sudden severe swelling, signs of infection, or symptoms that feel urgent, please seek medical care promptly.

Raegan Brumer, operating as Lavelle Health.