Your Name (required)
Your Email (required)
Telephone (required)
Has a physician or chiropractor recommended massage as a treatment for your pain? (required)
YesNo
Has your doctor ever advised against massage? (required)
Is your pain due to a recent trauma? (required)
Are you currently in pain? (required)
Please describe briefly where your discomfort is
Would you like special attention to any body parts during your massage?
Which areas?
List all medications you are currently taking
List all surgeries
List any conditions for which you have received medical treatment in the past 12 months
Have you been in close contact with or cared for someone who you suspect has COVID 19 within the past 20 days? (required)
Within the past 3 days have you had a fever? (required)
Within the past 3 days have you had a sore throat? (required)
Within the past 3 days have you experienced a new loss of taste or smell? (required)
Within the past 3 days have you experienced a cough? (required)
Within the past 3 days have you experienced shaking with chills? (required)
Females Only:
Are you pregnant or think that you may be pregnant?
Acknowledgment and acceptance of disclaimer:
-I understand and accept that massage therapy given here is for the purpose of, but not limited to: Fulfilling a prescription of a treating physician, for a medically necessary condition; for stress reduction, relief from muscular tension, or spasm; or for increasing circulation and energy flow.
-I understand and accept that the Massage Therapist does not diagnose illness, disease, or any other physical or mental disorder. Massage therapy is not a substitute for medical examinations and/or diagnosis. It is recommended that I see a physician for any physical ailment that I might have. Because a Massage Therapist must be aware of existing physical conditions, I have stated all of my known medical conditions and take it upon myself to keep the Massage Therapist updated on my physical health.
-I will respect the time of my Massage Therapist(s) and other clients. I agree to come to my scheduled appointments promptly, barring any unforeseen emergency. I understand that if I cancel later than 8 hours prior to my appointment, I will have to pay HALF the cost of my appointment. If I NO SHOW, I will have to pay the FULL price of the appointment.
Agree
Sign here: