Please Complete this Form Before Your Massage

Gender *
MaleFemale

Street Address *

How did you hear about us? *

Have you ever experienced a professional massage? *
YesNo

How Recently? *

Reason for Massage *

Are you under a physician’s care? *
YesNo

If yes, what for? *

Any accidents in the past 2 years? *

Do you have any of the following conditions? *
DiabetesInflammationNumbnessCancerAllergiesFibromyalgiaHeart DiseaseCirculatory DisorderUntreated High Blood PressureNone

Anything not listed? *

Please list any medications you are currently taking *

Do you have any allergies or sensitivities to oils, lotions, or scents? *

What are the appropriate areas of concern? (Please click H for High, M for Medium, L for Low) *

Headache
HML

Upper Back
HML

Lower Back
HML

Knee
HML

Neck/Shoulder
HML

Leg/Thigh
HML

Foot/Ankle H M L
HML

Other

Emergency Contact

I understand that the massage I receive is to provide for the basic purpose of relaxation, stress reduction, and relief from muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or stokes may be adjusted to my level of comfort.
I have given this information to the best of my knowledge and do not hold the therapist responsible for worsening any condition not stated above. I realize that massage therapy is not a substitute for a doctor’s care and will use it as a valuable addition to my healthcare.
It is also understood that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session.
I understand that a 1 hour massage time includes dressing and undressing. The actual hands on time can be anywhere from 50 to 55 minutes.

Signature *

Health Information-COVID-19 Information & Liability Waiver

COVID-19 Information

1. Have you had a fever in the last 24 hours of 100°F or above?
YesNo

2. Do you now, or have you recently had, any respiratory or fly symptoms, sore throat, or shortness of breath?
YesNo

3. Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms?
YesNo

Consent for Treatment

I understand that, because massage therapy work involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19.
By signing this form, I acknowledge that I am aware of the risks involved from receiving treatment at this time, I voluntarily agree to assume those risks, and I release and hold harmless the practitioner/business from any claims related thereto. I give my consent to receive treatment from this practitioner.