PRICING

Pricing

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All Seniors 65+, Military, and Law Enforcement receive a 15% discount

Massage

$150

60 minutes

$225

90 minutes

Package options

$405

3 X 60 minutes

$608

3 X 90 minutes

$675

5 X 60 minutes

$1012

5 X 90 minutes

Thermography

$699

Full Body

$549

Torso

$399

Breast

Mountain Stone Therapeutic

Schedule Your Appointment For Pain Relief Treatment

Mountain Stone Therapeutic Medical Massage And Thermography Initial Intake Form

Contact Us

NAME*

PHONE*

ADDRESS

CITY

STATE

ZIP

OCCUPATION

HOBBIES

EMERGENCY CONTACT

PHONE

ALLERGIES: Meds/Food/oils/lotions

PHYSICIAN

CHIROPRACTOR

Are you currently under their care for injury?

Yes

Do you have Prescription for therapy?

Are you currently on any pain meds or blood thinners

Yes

Were you referred?

Yes

If yes, by whom

Have you ever had a massage?

Yes

On a regular basis?

Yes

When was the last massage?

MEDICAL HISTORY

MEDICAL HISTORY

Prescribed Medication (pain meds & blood thinners)

On a scale of 1 -10 (1 best, 10 worst) please rate pain/discomfort level:

What is your quality of sleep and/or relaxation?

PLEASE READ CAREFULLY THE FOLLOWING INFORMATION AND SIGN WHERE INDICATED:

PLEASE READ CAREFULLY THE FOLLOWING INFORMATION AND SIGN WHERE INDICATED:

If I have any specific medical condition or specific symptoms that massage is contraindicated (should not be done), a referral form will be required from your Physician prior to massage being provided. Massage is not intended to substitute for any treatment or diagnosis of any physical or mental ailment. Massage Therapist is not trained or qualified to preform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness. I understand that massage is not to be construed as a substitute for medical examination, diagnosis, or treatment that I should see a Physician, Chiropractor, or other qualified medical specialist for any physical or mental ailment in which I am aware. I affirm I have stated all my known medical conditions and answered all questions honestly. I agree to keep the Massage Therapist updated as to any changes in my medical and physical profile as well as medication changes and understand there shall be no liability on the MT’s part should I forget to do so.

Mission Statement

Mission Statement: The goal of Mountain Stone Therapeutic Medical Massage is to provide effective massage treatment to the issues presented by our clients. During initial session we are looking for a full history of your conditions/issues whether chronic or recent. We assess your needs with your full cooperation and consent to give the best possible massage techniques to assist your body through the healing process. We keep up with current massage techniques to better ourselves and to be effective to our clients. Our total motivation is to see that you receive quality care and that you leave our office doing better than when you came in.

*A physician’s release is required for any accident or injury that is being monitored by your doctor.

*If you have taken blood thinners or pain medication in the past 12 hours you are required to give the therapist the name of medication, the amount, and the time taken. *No student under the age of 18 will be seen without a parent or guardian present for the entire time of the massage session.

* Allergies to medications, foods, oils, and lotions will be addressed at initial session and updated as needed.

At no time will any inappropriate behavior, comments, gestures, or threats be allowed from the client or therapist. If the therapist stops the session for any such reason the client will be charged for the full session. All massage therapists will be asking what degree of pressure you are comfortable with before and during the massage. You will be in control of the massage from the beginning to the end of the session. During massage it is our intent to help the healing process as well as help reduce muscular tension and stress. We will encourage you to drink water before and after each massage session. If you have any questions about the massage or techniques used, we will do our very best to answer or find the answer for you. Thank you for your patronage!

Free Text

We are 100% committed to your satisfaction.

Please read, initial, and sign this policy to ensure you have a great experience with us.

Client Name

Date

CANCELLATIONS/RESCHEDULING:

If I am not able to make a scheduled appointment, I agree to cancel or reschedule the appointment 24+ hours in advance. I agree to pay 50% of the full session rate if I give less than 24 hours’ notice.

Less than 24 hours, If I’m unable to make my appointment, I will inform Mountain Stone Therapeutic Medical Massage right away, and if you are unable to fill my vacancy, I will pay the cancellation fee.

I agree to pay the full session rate if I give notice 12 hours’ or less, or if I miss an appointment without giving notice.

I understand that I am still responsible for my appointment until I hear back from a staff member confirming they received my phone call or text requesting cancellation/rescheduling.

ARRIVING ON TIME/SESSION LENGTH

I understand to receive the full session time I have scheduled; I must arrive prior to the time of my scheduled appointment. If I arrive late, I understand that the therapist can only give me the time that remains of my appointment, and I will pay for the full length of the session that I scheduled.

I understand for me to receive the best massage therapy possible, I need to communicate my needs, preferences, requests, and/or feedback, at any time before, during or after my massage. I take it upon myself to communicate immediately if there is anything distracting me or if I feel unwell or uncomfortable at any time during the session so that adjustments can be made. I understand that my therapist wants my honest feedback-positive or negative-and does not take offense to it.

I have read, understand, and agree with the above policies and information.

Please add your name as your signature

Date