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Intake Form

Please fill out the following form
in order to participate in our activity.

Do you have any conditions that require doctor’s permission to participate in a massage session?
If the answer to the above question was 'yes', do you have a doctor’s permission to participate in a massage session?
Please look over the list of health disorders and check all that apply.
Are you pregnant?

I have agreed to voluntarily participate as a client for massage therapy, including, but not limited to, strength training, flexibility development, and aerobic exercise, under the guidance of Kat De Camillo (hereafter referred to as Massage Therapist/Facility). 

 

I hereby stipulate and agree that I am physically and mentally sound and currently have no physical conditions that would be aggravated by receiving a massage.

  • I understand that I assume all risks from receiving a massage and I am aware that participating in these types of activities, even when completed properly, can be dangerous. 

  • I agree to follow the verbal instructions issued by the therapist. I am aware that potential risks associated with these types of activities include but are not limited to: death, fainting, disorders in heartbeat, and serious neck and spinal injuries that may result in complete or partial paralysis or brain damage, serious injury to all bones, joints, ligaments, muscles, tendons, and other aspects of the musculoskeletal system, and serious injury or impairment to other aspects of my body, general health, and well-being.

  • If I experience any pain or discomfort during the session, I will immediately inform the massage therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that Massage Therapy 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. 

  • Because Massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. Should I waive the need for a physicians consent and proceed with massage I understand that I accept full responsibility and agree that no affiliated party will hold the massage therapist liable for any injury or worsening of condition from moving forward with the massage. 

  • I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so. 

  • Male and female genitalia and women’s breasts will not be exposed or touched at any time. Draping will be used for your privacy and comfort. Our policy requires the use of draping with sheets/ blankets at all times during every massage session.

  • I understand that massage therapy is provided for stress reduction, relaxation, relief from muscular tension, and improvement of circulation and energy flow.

  • If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/strokes can be adjusted to my level of comfort. I will not hold my therapist responsible for any pain or discomfort I experience during or after the session.

  • I understand that the services offered today are not a substitute for medical care. I understand that my therapist is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness.

  • I affirm that I have notified my therapist of all known medical conditions and injuries.

  • I agree to inform the therapist of any changes in my health and medical condition. I understand that there shall be no liability on the therapist’s part should I forget to do so.

  • I understand that massage is entirely therapeutic and non-sexual in nature.

  • By signing this release, I hereby waive and release my therapist from any and all liability, past, present, and future relating to massage therapy and bodywork.

  • I understand that I am responsible for my own medical insurance and will maintain that insurance throughout my entire period of participation as a massage client. I will assume and additional expenses incurred that go beyond my health coverage. I will notify the Massage Therapist/Facility of any significant injury that require medical attention (such as emergency care, hospitalization, etc.).

  • Massage Therapist/Facility or I will provide the equipment to be used in connection with the massage practice sessions, including, but not limited to, sheets, tables, oils, lotions and similar items. I represent and warrant any and all equipment I provide for sessions is for personal use only. Massage Therapist /Facility has not inspected my equipment and and has no knowledge of its condition. I understand that I take sole responsibility for my equipment. I acknowledge that although Massage Therapist/Facility takes precautions to maintain the equipment, any equipment may malfunction and/or cause potential injuries. I take sole responsibility to inspect any and all of my or the Massage Therapist/Facility equipment prior to use.

  • Although Massage Therapist/Facility will take precautions to ensure my safety, I expressly assume and accept sole responsibility for my safety and for any and all injuries that may occur. In consideration of the acceptance of this entry. I, for myself and for my executors, administrators, and assigns, waive and release any and all claims against Massage Therapist/Facility and any of their staffs, officers, officials, volunteers, sponsors, agents, representatives, successors, or assigns and agree to hold that harmless from any claims or losses, including but not limited to claims for negligence for any injuries or expenses that I may incur while exercising or while traveling to and from massage sessions. These exculpatory clauses are intended to apply to any and all activities occurring during the time or which I have contracted with Massage Therapist/Facility.

I represent and warrant that I am signing this agreement freely and willfully and not under any fraud or duress.

 

HAVING READ THE ABOVE TERMS AND INTENDING TO BE LEGALLY BOUND HEREBY AND UNDERSTANDING THIS DOCUMENT TO BE A COMPLETE WAIVER AND DISCLAIMER IN FAVOR OF FITNESS/MASSAGE PROFESSIONAL/FACILITY, I HEREBY AFFIX MY SIGNATURE HERETO.

Thanks for submitting!

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