Consultation & Health Intake: the full procedure
Collect a written health intake and verbal consultation to set goals, capture consent, and screen for anything that should be cleared by a physician before bodywork begins.
- Applies to: Massage therapist (LMT) / esthetician.
- Frequency: First visit, then re-verified every session.
- Scope: Covers the intake and consent process only. Every health condition, medication, or contraindication is referred to the client’s physician and the therapist’s license — never diagnosed or treated at the spa.
What you need
- Client intake form
- Health-history questionnaire
- Informed-consent form
- Pen / tablet
- Secure client file
The procedure, step by step
- Provide the intake form — Give every new client AMTA/ABMP-style intake and health-history paperwork to complete before the appointment starts.
- Verify identity & contact — Confirm name, emergency contact, and that the client is the person on file.
- Review health history — Read through listed conditions, surgeries, injuries, pregnancy, and current medications with the client out loud.
- Flag & refer out — Any condition, medication, or symptom that may make a treatment unsafe is documented and referred to the client’s physician for clearance — never cleared by the therapist.
- Set goals & pressure — Ask what the client wants from the session and their preferred pressure, focus areas, and areas to avoid.
- Obtain informed consent — Walk through what the session involves and have the client sign the consent form before any hands-on work.
- Note areas to avoid — Record sensitive areas, recent injuries, or client-requested no-touch zones in the file.
- File securely — Store completed forms in the client’s confidential record per spa privacy policy.
Quality check before you finish
- Intake form complete and signed.
- Medications and conditions documented.
- Physician-clearance items flagged and referred.
- Goals and pressure preferences recorded.
- Informed consent obtained before touch.
- Areas-to-avoid noted.
- Forms stored securely and confidentially.
This is a free, source-anchored standard operating procedure (SOP) you can print and hand to staff. It documents the work sequence for a Day Spa & Massage business — not safety or regulatory rulings, which defer to the cited authorities, the applicable code, and your own health-and-safety plan. Open the tool above to print it, toggle ink-saver, or (with a free ToolFluency Business account) edit it to match your own workflow.
Sources
- AMTA — Client Intake Form (amtamassage.org)
- ABMP — Client Health-History & Screening (abmp.com)
About Free Massage Consultation & Intake SOP for Day Spas
Free printable SOP for massage client consultation and health intake: screen contraindications, set goals, capture informed consent, and refer out to a physician.
How to use
- Read the full procedure top to bottom before the work — the SOP runs in order and each step builds on the last.
- Toggle Ink-saver (black & white) for a cheaper mono print for the binder; leave it off for the full-color version.
- Click Print SOP to print or save as PDF. Print one per crew, laminate it for the binder, or attach it to the job in your scheduling system.
- Train new hires on it and have staff sign off. Found something out of date? Use the feedback link — flagged SOPs are re-researched against the source list.
Frequently asked questions
Do therapists decide if a medical condition is safe to massage?
No. Therapists screen and document, but any condition, medication, or contraindication is referred to the client’s physician for clearance — the spa never diagnoses or overrides medical advice.
How often is the intake updated?
A full intake is taken on the first visit and verbally re-verified every session so new injuries, medications, or conditions are caught before hands-on work.
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