First name

Last name

Please check boxes below if any of the following are true:

Yes, I have COVID-19 Symptoms

No, I do not have COVID-19 Symptoms

COVID Symptoms Questionnaire

Have had a fever within the last 24 hours

Recently experienced respiratory/flu symptoms, sore throat, or shortness of breath

Contact, within the last 14 days, with anyone diagnosed with COVID or related symptoms

Respiratory

Check Yes if you have Respiratory Issues

Asthma

Shortness of Breath

Bronchitis

Chronic Cough

Emphysema

Cardiovascular

Check Yes if you have Cardiovascular Issues

Blood Clots

Cold Hands

High Blood Pressure

Pacemaker

Varicose Veins

Cardiovascular Accident

Congestive Heart Failure

Low Blood Pressure

Phlebitis

Cerebral-Vascular Accident

Heart Attack

Stroke

Lymphedema

Cold Feet

Heart Disease

Thrombosis/Embolism

Myocardial Infarction

Skin

Check Yes if you have Skin Issues

Bruise Easily

Skin Irritations

Hypersensitive Reaction

Melanoma

Skin Conditions

Head & Neck

Check Yes if you have Head & Neck Issues

Ear Problems

Hearing Loss

Sinus Problems

Vision Problems

Vision Loss

Migraines

Headaches

Jaw Pain (TMJD)

COVID SYMPTOM RELEASE FORM

CONSENT RELEASE FORM

First name

Last name

Infectious Conditions

Check Yes if you have Infectious Conditions

Athlete's Foot

Respiratory Conditions

Hepatitis

Skin Conditions

HIV

Herpes

Reproductive

Check Yes if you have Reproductive Issues

Pregnancy

Gynecological Issues

Family History

Check Yes if you have any of these issues in your Family History

Cardiovascular Conditions

Respiratory Conditions

Neurological

Check Yes if you have Neurological Issues

Burning

Numbness

Tingling

Stabbing Pain

Cerebral Palsy

Parkinsons

Multiple Sclerosis

Herniated Disc

Miscellaneous

Check Yes if you have any of these Miscellaneous Issues

Allergies

Cancer

Dizziness

Hemophila

Mental Illness

Surgical Pins or Wire

Anaphylaxis

Crohn's Disease

Epilepsy

Arthritis

Osteoarthritis

Rheumatoid Arthritis

Artificial Joints/Special Equipment

Diabetes

Fibromyalgia

Loss of Sensation

Osteoporosis

Shingles

Stress

Digestive Conditions

Insomnia

Gout

Lupus

Other Diagnosed Diseases

Other Medical Conditions

Allergies and other conditions your provider should be aware of?

Please list any medications or drugs you are currently using

Please take a moment to read the following:

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

Yes

If I experience pain or discomfort during my 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

Yes

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, diagnosis, prescribe, or treat physical or mental illness

Yes

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

Yes

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

Yes

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.

Yes

Signature*

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Sign Above

I have read the statement above and agree to all the policies.

FAQS

We have answers!

How do you take payments?

All cash deposits are welcome. Customers can also send payments using PayPal or Venmo.

What are your session times?

60 minute, 90 minute, and 120 minute of integrative massage.

What are your speciality massages?