Intake Form

Required Field

The information request below will assist us in treating you safely. Feel free to ask any questions about the information being requested. Please note that all information provided below will be kept confidential unless allowed or required by law. Your written permission will be required to release any information.

Personal Info
Contact Info
Emergency Contact
Doctor
Additional Information
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Medications
Injuries
Surgeries
Conditions
Muscle / Joint
Head / Neck
Cardiovascular
Respiratory
Blood
Gastrointestinal
Skin
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Women
Other Conditions
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Massage Therapy Informed Consent (Breast / Chest & Glute Treatment)

Purpose of Treatment

I understand that massage therapy provided by Yaima Massage & Movement is performed for therapeutic purposes only, including pain relief, injury recovery, postural support, movement improvement, and functional performance.

Certain conditions may require treatment of sensitive areas such as the chest/breast region or gluteal muscles when clinically appropriate.

 

Breast / Chest Area Treatment (Therapeutic Only)

I understand that therapeutic treatment of the chest/breast area may be indicated for medical or functional reasons such as postural dysfunction, shoulder or neck conditions, scar tissue, lymphatic drainage, or movement restriction.

  • Treatment will be performed only with my informed consent
  • Proper draping will be always maintained
  • Only the specific area being treated will be exposed
  • Breast/chest treatment is never performed for relaxation or non-clinical purposes I may request modification or stop treatment at any time o The gluteal cleft and genital areas will always remain covered o Treatment is strictly professional and therapeutic o I may request modification or stop treatment at any time

 

Gluteal Muscle Treatment

I understand that the gluteal muscles are a major muscle group commonly treated for low back pain, hip dysfunction, gait issues, and sports-related conditions.

  • The gluteal cleft and genital areas will always remain covered
  • Treatment is strictly professional and therapeutic
  • I may request modification or stop treatment at any time

 

Clinical Photos & Communication Consent

Clinical Photos & Documentation (Rquired)

Clinical photos and/or videos (such as posture assessment, movement screening, or self-care exercise demonstrations) may be taken as part of your treatment. These images are used to document your condition, support clinical assessment, guide treatment planning, and track progress over time. These materials become part of your confidential clinical record and are handled in accordance with applicable privacy laws.

Optional Use for Education, Marketing, or Public Materials

Non-identifiable photos or videos may be helpful for professional education, workshops, case studies, website content, or social media. Identifiable images will never be used without additional, specific written consent.

Review & Agree