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Health Waiver Form

Please fill out the following form to provide more information prior to your appointment. 

Have you had a professional massage before?
Have you been sick in the last week?
Have you had surgery or been hospitalized in the last 12 months?
Are you suffering from a medical condition, illness, or injury?
Head and Neck
Cardiovascular
Musculoskeletal
Neurological
Respiratory
Skin
Autoimmune Conditions
Miscellaneous

Waiver

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Please read and sign:

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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 today's services are not a substitute for medical care and that my therapist is not qualified to diagnose, prescribe, or treat physical/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 and 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. Any solicitation will result in either a refusal to accept an appointment, immediate termination of treatment, and mandatory reporting to authorities. Solicitation is illegal.

 

If under 18, signature of parent or legal guardian is required. 


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

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Integral Massage & Therapeutics // Christopher Leeder LMT

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