Health History and Consent

| Resume a previously saved form
Resume Later

In order to be able to resume this form later, please enter your email and choose a password.



( )
-
( )
-
( )
-

Home Address



Mailing Address








( )
-



Health History
Please take a moment to carefully read the following information. If you have a specific medical condition or specific symptoms, massage/bodywork may be contraindicated. A referral from your primary care provider may be required prior to treatment.






Conditions
Please check any conditions you currently have or have had in the past. If a text box appears for any condition you check, please explain it in the box.



































































































Daily Consumption Quantities of:







Female Clients Only:







By checking the boxes below, I agree to abide by the policies set forth by Body Spa & Massage, LLC.
Appointment Policies
  • Please arrive 5 minutes early so we may start at your scheduled time.
  • Late arrivals will still end at the scheduled time.
  • Please call 24 hours in advance to reschedule or candel your appointment.
  • If you are sick the day of your appointment, please call and reschedule.
  • No shows will be charged the full amount of the service scheduled. A payment for the no show appointment must be received by Body Spa & Massage, LLC before scheduling a new appointment.

Consent Statement
I understand that the massage/bodywork I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage or bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner's part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.


Captcha

Please enter the characters you see in this picture:

Visual CAPTCHA

This helps prevent automated form submissions. If you are not sure what the characters are, make your best guess. You will have another try in the next screen.
Can't see the image? Click here for an audible version in English.

Need assistance with this form?