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Intake Form

Please fill out this intake form prior to you appointment!  If a submission is not received we will go over it before your session begins.  Please note, this may take away from your session time.  

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Updated forms will be required every 6 months.

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Thank you!

Are there any areas you'd like to focus on?

Medical History

Do you have a history with any of the following medical conditions?
Are you currently experiencing any abnormal swelling?
Yes
No

Cupping Disclaimer

The intent of a massage cupping treatment is not to leave cup marks on the body. However, in some instances, these marks can happen. By agreeing below, you are acknowledging that you may have some temporary marks left on the treatment area.

Hot Stone Massage


Hot stone massage is a type of massage therapy that uses smooth, heated stones to provide a relaxing and warming effect to a therapeutic massage. The therapist will typically hold a heated stone in each hand while applying various massage techniques such as long gliding strokes, vibration, friction, deep tissue techniques, or trigger point therapy. Using the heated stones as a tool in this way enables the client to benefit from the physiological effects of pressure and heat.


I have provided my therapist with an accurate and complete medical history to rule out any contraindications to receiving this treatment.


I understand that the temperature of the stones should always be within my comfort level, and I agree to communicate to my therapist about any physical discomfort that I experience during the session.


Information about hot stone massage, potential benefits, effects, risks, and possible alternative therapies have been

explained to me and I understand this information.


I have been given an opportunity to ask questions about hot stone massage and have had my questions answered to

my satisfaction.


I have no contraindications for hot stone massage.


I release the massage therapist and business from all liability for any harm that may unintentionally result from this treatment.

Please read carefully and sign where indicated:

1. I understand that massage or bodywork may be contraindicated for certain medical conditions or symptoms. A referral from my physician or licensed health care provider may be necessary prior to service being provided.

2. I further understand that massage or bodywork is provided for the purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during my appointment, I will inform the therapist so that the pressure or strokes may be adjusted accordingly.

3. I understand that massage or bodywork should not be perceived by me as a substitute for medical examination, diagnosis, or treatment and that I should consult a physician, chiropractor, or other qualified medical specialist for any mental or physical condition that I am aware of.

4. I have been informed that massage and bodywork therapists are not qualified to perform skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said during the session should be perceived as such.

5. I understand that our massage therapists are trained professionals. At all times I will adhere to state and ethical compliant rules on draping and etiquette. Under professional guidelines our massage therapist employs full sheet draping to protect client modesty. The practitioner maintains the right to terminate a bodywork and massage session at will. I understand that any remarks or actions of a sexual or personal nature will result in immediate termination of the session and that no future appointments will be allowed.

6. Because massage or bodywork should not be performed under certain medical conditions, I attest that I have stated all my known medical conditions and answered all questions honestly. I accept and voluntarily assume all risks of injury.


By signing below you are agreeing to treatment done by Jenny DiNuoscio at Jenny D Luxury in Charlotte, NC.

PHOTO RELEASE FORM

JENNY D LUXURY

Photography is not a common practice for every session at Jenny D Luxury. However, in some instances, photos may be taken at the approval of the client.


Those instances are listed below:

  • Progression photos for clients file only.

  • Client request for therapist to take a photo during their session so that they may see their progress, post to social media, or save for their own personal record.

  • Photo models that have willingly and knowingly volunteered to be photographed for marketing and/or social media.


This photo release is strictly for clients that are authorizing Jenny D Luxury to use their photos for marketing or social media posting. Any photo taken for client's file WILL NOT be publicly released.


I hereby grant Jenny D Luxury, the irrevocable and unrestricted right to use, reproduce, and publish photographs and/or video recordings of me, taken for the purpose of promoting and marketing services through various channels, including but not limited to Jenny D Luxury's website, social media platforms, brochures, and other promotional materials.


I understand and agree that:


The images may be used indefinitely, without any limitation on the duration of usage.


The images may be used in any form, format, or medium, whether now known or hereafter created, including print, digital, electronic, or online platforms.


The images may be altered, edited, or modified as deemed appropriate, without further consent from me.


I will not receive any compensation, payment, or royalty for the use of the images, and I hereby waive any right to such compensation, payment, or royalty.


I have the right to revoke this permission at any time by providing written notice to Jenny D Luxury. Upon receipt of such notice, Jenny D Luxury will cease the use of the images in any new promotional materials and will make reasonable efforts to remove the images from existing materials, where feasible.


By signing below, I represent that I am at least 18 years old and have the legal capacity to enter into this agreement.

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