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Massage Health Waiver

When you book a massage with Purify Wellness Center, you agree to this cancellation policy and the following terms: We ask that you give us the courtesy of 24 hours (or more) notice of a cancellation or any change to your scheduled massage. Any cancellations with less than 24 hours of notice are subject to a cancellation fee of $50 ($100 for a couples massage, for the two therapists). Cancellation fees will automatically be billed to the customers credit card on file, and we do keep credit cards on file for this purpose. 

Cancellation notifications must call in (801-854-5153) during business hours, and talk to a live person with 24 (or more) hours notice. Cancellations CANNOT be issued through email, text, our online bot, or voicemail (to make sure we get the cancellation in time to let the therapist know of the change you made to their schedule). If you issue your cancellation notice via email, text, our online bot, or voicemail, or after normal business hours, you will still get charged the cancellation fee as it was not received with 24 hours notice. Clients who miss their appointments without giving any prior notification will be charged in full for the scheduled service.

I Agree

Today's Date: May 5, 2024

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
Is this your first massage?*
No
Yes
Do you bruise easily?*
No
Yes
Are you sensitive to smells?*
No
Yes
If female, are you pregnant?*
No
Yes

If so, how many weeks along?

List all medications you are taking:

List all allergies here:

Please read over this list carefully and check the box of any issue you have or have had: 

Muscular, Skeletal
Headaches/Migraines
Arthritis or Joint Pain
Back Pain
Hip Pain
Spinal Disc Issues/Fusion
Neck Pain
Shoulder/Arm/Hand Pain
Hip/Leg/Knee/Foot Pain
TMJ/Jaw Pain
Swollen/Stiff Joints
Broken Bones
Strains/Sprains
Scoliosis
Skin Issues
Skin Conditions
Warts
Athlete’s Foot
Rashes
Circulatory, Respiratory
Respiratory Problems
Asthma
Sinus Issues
Edema/Swelling
Blood clots
High Blood Pressure
Low Blood Pressure
Circulatory Issues
Anemia
Chest Pain
Stroke
History of Stroke in Family
Heart Problems
History of Heart Problems in Family
Vein/Artery Problems
Varicose Veins
Seizures/Convulsions
Numbness/Tingling
Miscellaneous
Contagious Illnesses or Diseases
Autoimmune Issues
Fibromyalgia
Implants: IUD’s, pacemakers, breast or dental implants
Digestive Issues
Liver problems
Kidney Issues
Diabetes (Type 1 or 2)
Cancer
Menstrual Problems
C-Section
Depression/Anxiety
Surgeries (explain below)
Injuries (explain below)
Sleep Problems

Use this box to describe any of the issues above, or to describe any other conditions or issues of concern. Explanation/dates occurred:

● By signing this form I give my consent to be treated, and understand all information provided is confidential.

● It is my responsibility to inform the therapist if there is any pain or discomfort during the session.

● It is my responsibility to inform the therapist if I would like an adjustment to the massage pressure being used.

● I understand massage and foot zones are not a substitute for medical examinations, diagnosis, or treatment. I’m aware I should see a qualified healthcare provider for any medical or mental issues I’m aware of.

● I understand that massage therapists or foot zone practitioners are not qualified to diagnose, prescribe, or treat for any physical or mental illness, and nothing said during any session should be considered as such.

● At any time, the practitioner has the right to refuse service for any reason.

● Because massage or foot zoning can be contraindicated under certain medical conditions, I affirm I have disclosed all known medical conditions, and answered all questions honestly. I agree to keep the practitioner updated on any changes to my medical profile, and understand there shall not be liability on the practitioner's part if I forget to do so.


First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
Is this your first massage?*
No
Yes
Do you bruise easily?*
No
Yes
Are you sensitive to smells?*
No
Yes
If female, are you pregnant?*
No
Yes

If so, how many weeks along?

List all medications you are taking:

List all allergies here:

Please read over this list carefully and check the box of any issue you have or have had: 

Muscular, Skeletal
Headaches/Migraines
Arthritis or Joint Pain
Back Pain
Hip Pain
Spinal Disc Issues/Fusion
Neck Pain
Shoulder/Arm/Hand Pain
Hip/Leg/Knee/Foot Pain
TMJ/Jaw Pain
Swollen/Stiff Joints
Broken Bones
Strains/Sprains
Scoliosis
Skin Issues
Skin Conditions
Warts
Athlete’s Foot
Rashes
Circulatory, Respiratory
Respiratory Problems
Asthma
Sinus Issues
Edema/Swelling
Blood clots
High Blood Pressure
Low Blood Pressure
Circulatory Issues
Anemia
Chest Pain
Stroke
History of Stroke in Family
Heart Problems
History of Heart Problems in Family
Vein/Artery Problems
Varicose Veins
Seizures/Convulsions
Numbness/Tingling
Miscellaneous
Contagious Illnesses or Diseases
Autoimmune Issues
Fibromyalgia
Implants: IUD’s, pacemakers, breast or dental implants
Digestive Issues
Liver problems
Kidney Issues
Diabetes (Type 1 or 2)
Cancer
Menstrual Problems
C-Section
Depression/Anxiety
Surgeries (explain below)
Injuries (explain below)
Sleep Problems

Use this box to describe any of the issues above, or to describe any other conditions or issues of concern. Explanation/dates occurred:

● By signing this form I give my consent to be treated, and understand all information provided is confidential.

● It is my responsibility to inform the therapist if there is any pain or discomfort during the session.

● It is my responsibility to inform the therapist if I would like an adjustment to the massage pressure being used.

● I understand massage and foot zones are not a substitute for medical examinations, diagnosis, or treatment. I’m aware I should see a qualified healthcare provider for any medical or mental issues I’m aware of.

● I understand that massage therapists or foot zone practitioners are not qualified to diagnose, prescribe, or treat for any physical or mental illness, and nothing said during any session should be considered as such.

● At any time, the practitioner has the right to refuse service for any reason.

● Because massage or foot zoning can be contraindicated under certain medical conditions, I affirm I have disclosed all known medical conditions, and answered all questions honestly. I agree to keep the practitioner updated on any changes to my medical profile, and understand there shall not be liability on the practitioner's part if I forget to do so.


Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
Is this your first massage?*
No
Yes
Do you bruise easily?*
No
Yes
Are you sensitive to smells?*
No
Yes
If female, are you pregnant?*
No
Yes

If so, how many weeks along?

List all medications you are taking:

List all allergies here:

Please read over this list carefully and check the box of any issue you have or have had: 

Muscular, Skeletal
Headaches/Migraines
Arthritis or Joint Pain
Back Pain
Hip Pain
Spinal Disc Issues/Fusion
Neck Pain
Shoulder/Arm/Hand Pain
Hip/Leg/Knee/Foot Pain
TMJ/Jaw Pain
Swollen/Stiff Joints
Broken Bones
Strains/Sprains
Scoliosis
Skin Issues
Skin Conditions
Warts
Athlete’s Foot
Rashes
Circulatory, Respiratory
Respiratory Problems
Asthma
Sinus Issues
Edema/Swelling
Blood clots
High Blood Pressure
Low Blood Pressure
Circulatory Issues
Anemia
Chest Pain
Stroke
History of Stroke in Family
Heart Problems
History of Heart Problems in Family
Vein/Artery Problems
Varicose Veins
Seizures/Convulsions
Numbness/Tingling
Miscellaneous
Contagious Illnesses or Diseases
Autoimmune Issues
Fibromyalgia
Implants: IUD’s, pacemakers, breast or dental implants
Digestive Issues
Liver problems
Kidney Issues
Diabetes (Type 1 or 2)
Cancer
Menstrual Problems
C-Section
Depression/Anxiety
Surgeries (explain below)
Injuries (explain below)
Sleep Problems

Use this box to describe any of the issues above, or to describe any other conditions or issues of concern. Explanation/dates occurred:

● By signing this form I give my consent to be treated, and understand all information provided is confidential.

● It is my responsibility to inform the therapist if there is any pain or discomfort during the session.

● It is my responsibility to inform the therapist if I would like an adjustment to the massage pressure being used.

● I understand massage and foot zones are not a substitute for medical examinations, diagnosis, or treatment. I’m aware I should see a qualified healthcare provider for any medical or mental issues I’m aware of.

● I understand that massage therapists or foot zone practitioners are not qualified to diagnose, prescribe, or treat for any physical or mental illness, and nothing said during any session should be considered as such.

● At any time, the practitioner has the right to refuse service for any reason.

● Because massage or foot zoning can be contraindicated under certain medical conditions, I affirm I have disclosed all known medical conditions, and answered all questions honestly. I agree to keep the practitioner updated on any changes to my medical profile, and understand there shall not be liability on the practitioner's part if I forget to do so.


Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
Is this your first massage?*
No
Yes
Do you bruise easily?*
No
Yes
Are you sensitive to smells?*
No
Yes
If female, are you pregnant?*
No
Yes

If so, how many weeks along?

List all medications you are taking:

List all allergies here:

Please read over this list carefully and check the box of any issue you have or have had: 

Muscular, Skeletal
Headaches/Migraines
Arthritis or Joint Pain
Back Pain
Hip Pain
Spinal Disc Issues/Fusion
Neck Pain
Shoulder/Arm/Hand Pain
Hip/Leg/Knee/Foot Pain
TMJ/Jaw Pain
Swollen/Stiff Joints
Broken Bones
Strains/Sprains
Scoliosis
Skin Issues
Skin Conditions
Warts
Athlete’s Foot
Rashes
Circulatory, Respiratory
Respiratory Problems
Asthma
Sinus Issues
Edema/Swelling
Blood clots
High Blood Pressure
Low Blood Pressure
Circulatory Issues
Anemia
Chest Pain
Stroke
History of Stroke in Family
Heart Problems
History of Heart Problems in Family
Vein/Artery Problems
Varicose Veins
Seizures/Convulsions
Numbness/Tingling
Miscellaneous
Contagious Illnesses or Diseases
Autoimmune Issues
Fibromyalgia
Implants: IUD’s, pacemakers, breast or dental implants
Digestive Issues
Liver problems
Kidney Issues
Diabetes (Type 1 or 2)
Cancer
Menstrual Problems
C-Section
Depression/Anxiety
Surgeries (explain below)
Injuries (explain below)
Sleep Problems

Use this box to describe any of the issues above, or to describe any other conditions or issues of concern. Explanation/dates occurred:

● By signing this form I give my consent to be treated, and understand all information provided is confidential.

● It is my responsibility to inform the therapist if there is any pain or discomfort during the session.

● It is my responsibility to inform the therapist if I would like an adjustment to the massage pressure being used.

● I understand massage and foot zones are not a substitute for medical examinations, diagnosis, or treatment. I’m aware I should see a qualified healthcare provider for any medical or mental issues I’m aware of.

● I understand that massage therapists or foot zone practitioners are not qualified to diagnose, prescribe, or treat for any physical or mental illness, and nothing said during any session should be considered as such.

● At any time, the practitioner has the right to refuse service for any reason.

● Because massage or foot zoning can be contraindicated under certain medical conditions, I affirm I have disclosed all known medical conditions, and answered all questions honestly. I agree to keep the practitioner updated on any changes to my medical profile, and understand there shall not be liability on the practitioner's part if I forget to do so.


Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
Is this your first massage?*
No
Yes
Do you bruise easily?*
No
Yes
Are you sensitive to smells?*
No
Yes
If female, are you pregnant?*
No
Yes

If so, how many weeks along?

List all medications you are taking:

List all allergies here:

Please read over this list carefully and check the box of any issue you have or have had: 

Muscular, Skeletal
Headaches/Migraines
Arthritis or Joint Pain
Back Pain
Hip Pain
Spinal Disc Issues/Fusion
Neck Pain
Shoulder/Arm/Hand Pain
Hip/Leg/Knee/Foot Pain
TMJ/Jaw Pain
Swollen/Stiff Joints
Broken Bones
Strains/Sprains
Scoliosis
Skin Issues
Skin Conditions
Warts
Athlete’s Foot
Rashes
Circulatory, Respiratory
Respiratory Problems
Asthma
Sinus Issues
Edema/Swelling
Blood clots
High Blood Pressure
Low Blood Pressure
Circulatory Issues
Anemia
Chest Pain
Stroke
History of Stroke in Family
Heart Problems
History of Heart Problems in Family
Vein/Artery Problems
Varicose Veins
Seizures/Convulsions
Numbness/Tingling
Miscellaneous
Contagious Illnesses or Diseases
Autoimmune Issues
Fibromyalgia
Implants: IUD’s, pacemakers, breast or dental implants
Digestive Issues
Liver problems
Kidney Issues
Diabetes (Type 1 or 2)
Cancer
Menstrual Problems
C-Section
Depression/Anxiety
Surgeries (explain below)
Injuries (explain below)
Sleep Problems

Use this box to describe any of the issues above, or to describe any other conditions or issues of concern. Explanation/dates occurred:

● By signing this form I give my consent to be treated, and understand all information provided is confidential.

● It is my responsibility to inform the therapist if there is any pain or discomfort during the session.

● It is my responsibility to inform the therapist if I would like an adjustment to the massage pressure being used.

● I understand massage and foot zones are not a substitute for medical examinations, diagnosis, or treatment. I’m aware I should see a qualified healthcare provider for any medical or mental issues I’m aware of.

● I understand that massage therapists or foot zone practitioners are not qualified to diagnose, prescribe, or treat for any physical or mental illness, and nothing said during any session should be considered as such.

● At any time, the practitioner has the right to refuse service for any reason.

● Because massage or foot zoning can be contraindicated under certain medical conditions, I affirm I have disclosed all known medical conditions, and answered all questions honestly. I agree to keep the practitioner updated on any changes to my medical profile, and understand there shall not be liability on the practitioner's part if I forget to do so.


Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
Is this your first massage?*
No
Yes
Do you bruise easily?*
No
Yes
Are you sensitive to smells?*
No
Yes
If female, are you pregnant?*
No
Yes

If so, how many weeks along?

List all medications you are taking:

List all allergies here:

Please read over this list carefully and check the box of any issue you have or have had: 

Muscular, Skeletal
Headaches/Migraines
Arthritis or Joint Pain
Back Pain
Hip Pain
Spinal Disc Issues/Fusion
Neck Pain
Shoulder/Arm/Hand Pain
Hip/Leg/Knee/Foot Pain
TMJ/Jaw Pain
Swollen/Stiff Joints
Broken Bones
Strains/Sprains
Scoliosis
Skin Issues
Skin Conditions
Warts
Athlete’s Foot
Rashes
Circulatory, Respiratory
Respiratory Problems
Asthma
Sinus Issues
Edema/Swelling
Blood clots
High Blood Pressure
Low Blood Pressure
Circulatory Issues
Anemia
Chest Pain
Stroke
History of Stroke in Family
Heart Problems
History of Heart Problems in Family
Vein/Artery Problems
Varicose Veins
Seizures/Convulsions
Numbness/Tingling
Miscellaneous
Contagious Illnesses or Diseases
Autoimmune Issues
Fibromyalgia
Implants: IUD’s, pacemakers, breast or dental implants
Digestive Issues
Liver problems
Kidney Issues
Diabetes (Type 1 or 2)
Cancer
Menstrual Problems
C-Section
Depression/Anxiety
Surgeries (explain below)
Injuries (explain below)
Sleep Problems

Use this box to describe any of the issues above, or to describe any other conditions or issues of concern. Explanation/dates occurred:

● By signing this form I give my consent to be treated, and understand all information provided is confidential.

● It is my responsibility to inform the therapist if there is any pain or discomfort during the session.

● It is my responsibility to inform the therapist if I would like an adjustment to the massage pressure being used.

● I understand massage and foot zones are not a substitute for medical examinations, diagnosis, or treatment. I’m aware I should see a qualified healthcare provider for any medical or mental issues I’m aware of.

● I understand that massage therapists or foot zone practitioners are not qualified to diagnose, prescribe, or treat for any physical or mental illness, and nothing said during any session should be considered as such.

● At any time, the practitioner has the right to refuse service for any reason.

● Because massage or foot zoning can be contraindicated under certain medical conditions, I affirm I have disclosed all known medical conditions, and answered all questions honestly. I agree to keep the practitioner updated on any changes to my medical profile, and understand there shall not be liability on the practitioner's part if I forget to do so.


Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
Is this your first massage?*
No
Yes
Do you bruise easily?*
No
Yes
Are you sensitive to smells?*
No
Yes
If female, are you pregnant?*
No
Yes

If so, how many weeks along?

List all medications you are taking:

List all allergies here:

Please read over this list carefully and check the box of any issue you have or have had: 

Muscular, Skeletal
Headaches/Migraines
Arthritis or Joint Pain
Back Pain
Hip Pain
Spinal Disc Issues/Fusion
Neck Pain
Shoulder/Arm/Hand Pain
Hip/Leg/Knee/Foot Pain
TMJ/Jaw Pain
Swollen/Stiff Joints
Broken Bones
Strains/Sprains
Scoliosis
Skin Issues
Skin Conditions
Warts
Athlete’s Foot
Rashes
Circulatory, Respiratory
Respiratory Problems
Asthma
Sinus Issues
Edema/Swelling
Blood clots
High Blood Pressure
Low Blood Pressure
Circulatory Issues
Anemia
Chest Pain
Stroke
History of Stroke in Family
Heart Problems
History of Heart Problems in Family
Vein/Artery Problems
Varicose Veins
Seizures/Convulsions
Numbness/Tingling
Miscellaneous
Contagious Illnesses or Diseases
Autoimmune Issues
Fibromyalgia
Implants: IUD’s, pacemakers, breast or dental implants
Digestive Issues
Liver problems
Kidney Issues
Diabetes (Type 1 or 2)
Cancer
Menstrual Problems
C-Section
Depression/Anxiety
Surgeries (explain below)
Injuries (explain below)
Sleep Problems

Use this box to describe any of the issues above, or to describe any other conditions or issues of concern. Explanation/dates occurred:

● By signing this form I give my consent to be treated, and understand all information provided is confidential.

● It is my responsibility to inform the therapist if there is any pain or discomfort during the session.

● It is my responsibility to inform the therapist if I would like an adjustment to the massage pressure being used.

● I understand massage and foot zones are not a substitute for medical examinations, diagnosis, or treatment. I’m aware I should see a qualified healthcare provider for any medical or mental issues I’m aware of.

● I understand that massage therapists or foot zone practitioners are not qualified to diagnose, prescribe, or treat for any physical or mental illness, and nothing said during any session should be considered as such.

● At any time, the practitioner has the right to refuse service for any reason.

● Because massage or foot zoning can be contraindicated under certain medical conditions, I affirm I have disclosed all known medical conditions, and answered all questions honestly. I agree to keep the practitioner updated on any changes to my medical profile, and understand there shall not be liability on the practitioner's part if I forget to do so.


Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
Is this your first massage?*
No
Yes
Do you bruise easily?*
No
Yes
Are you sensitive to smells?*
No
Yes
If female, are you pregnant?*
No
Yes

If so, how many weeks along?

List all medications you are taking:

List all allergies here:

Please read over this list carefully and check the box of any issue you have or have had: 

Muscular, Skeletal
Headaches/Migraines
Arthritis or Joint Pain
Back Pain
Hip Pain
Spinal Disc Issues/Fusion
Neck Pain
Shoulder/Arm/Hand Pain
Hip/Leg/Knee/Foot Pain
TMJ/Jaw Pain
Swollen/Stiff Joints
Broken Bones
Strains/Sprains
Scoliosis
Skin Issues
Skin Conditions
Warts
Athlete’s Foot
Rashes
Circulatory, Respiratory
Respiratory Problems
Asthma
Sinus Issues
Edema/Swelling
Blood clots
High Blood Pressure
Low Blood Pressure
Circulatory Issues
Anemia
Chest Pain
Stroke
History of Stroke in Family
Heart Problems
History of Heart Problems in Family
Vein/Artery Problems
Varicose Veins
Seizures/Convulsions
Numbness/Tingling
Miscellaneous
Contagious Illnesses or Diseases
Autoimmune Issues
Fibromyalgia
Implants: IUD’s, pacemakers, breast or dental implants
Digestive Issues
Liver problems
Kidney Issues
Diabetes (Type 1 or 2)
Cancer
Menstrual Problems
C-Section
Depression/Anxiety
Surgeries (explain below)
Injuries (explain below)
Sleep Problems

Use this box to describe any of the issues above, or to describe any other conditions or issues of concern. Explanation/dates occurred:

● By signing this form I give my consent to be treated, and understand all information provided is confidential.

● It is my responsibility to inform the therapist if there is any pain or discomfort during the session.

● It is my responsibility to inform the therapist if I would like an adjustment to the massage pressure being used.

● I understand massage and foot zones are not a substitute for medical examinations, diagnosis, or treatment. I’m aware I should see a qualified healthcare provider for any medical or mental issues I’m aware of.

● I understand that massage therapists or foot zone practitioners are not qualified to diagnose, prescribe, or treat for any physical or mental illness, and nothing said during any session should be considered as such.

● At any time, the practitioner has the right to refuse service for any reason.

● Because massage or foot zoning can be contraindicated under certain medical conditions, I affirm I have disclosed all known medical conditions, and answered all questions honestly. I agree to keep the practitioner updated on any changes to my medical profile, and understand there shall not be liability on the practitioner's part if I forget to do so.


Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
Is this your first massage?*
No
Yes
Do you bruise easily?*
No
Yes
Are you sensitive to smells?*
No
Yes
If female, are you pregnant?*
No
Yes

If so, how many weeks along?

List all medications you are taking:

List all allergies here:

Please read over this list carefully and check the box of any issue you have or have had: 

Muscular, Skeletal
Headaches/Migraines
Arthritis or Joint Pain
Back Pain
Hip Pain
Spinal Disc Issues/Fusion
Neck Pain
Shoulder/Arm/Hand Pain
Hip/Leg/Knee/Foot Pain
TMJ/Jaw Pain
Swollen/Stiff Joints
Broken Bones
Strains/Sprains
Scoliosis
Skin Issues
Skin Conditions
Warts
Athlete’s Foot
Rashes
Circulatory, Respiratory
Respiratory Problems
Asthma
Sinus Issues
Edema/Swelling
Blood clots
High Blood Pressure
Low Blood Pressure
Circulatory Issues
Anemia
Chest Pain
Stroke
History of Stroke in Family
Heart Problems
History of Heart Problems in Family
Vein/Artery Problems
Varicose Veins
Seizures/Convulsions
Numbness/Tingling
Miscellaneous
Contagious Illnesses or Diseases
Autoimmune Issues
Fibromyalgia
Implants: IUD’s, pacemakers, breast or dental implants
Digestive Issues
Liver problems
Kidney Issues
Diabetes (Type 1 or 2)
Cancer
Menstrual Problems
C-Section
Depression/Anxiety
Surgeries (explain below)
Injuries (explain below)
Sleep Problems

Use this box to describe any of the issues above, or to describe any other conditions or issues of concern. Explanation/dates occurred:

● By signing this form I give my consent to be treated, and understand all information provided is confidential.

● It is my responsibility to inform the therapist if there is any pain or discomfort during the session.

● It is my responsibility to inform the therapist if I would like an adjustment to the massage pressure being used.

● I understand massage and foot zones are not a substitute for medical examinations, diagnosis, or treatment. I’m aware I should see a qualified healthcare provider for any medical or mental issues I’m aware of.

● I understand that massage therapists or foot zone practitioners are not qualified to diagnose, prescribe, or treat for any physical or mental illness, and nothing said during any session should be considered as such.

● At any time, the practitioner has the right to refuse service for any reason.

● Because massage or foot zoning can be contraindicated under certain medical conditions, I affirm I have disclosed all known medical conditions, and answered all questions honestly. I agree to keep the practitioner updated on any changes to my medical profile, and understand there shall not be liability on the practitioner's part if I forget to do so.


Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
Is this your first massage?*
No
Yes
Do you bruise easily?*
No
Yes
Are you sensitive to smells?*
No
Yes
If female, are you pregnant?*
No
Yes

If so, how many weeks along?

List all medications you are taking:

List all allergies here:

Please read over this list carefully and check the box of any issue you have or have had: 

Muscular, Skeletal
Headaches/Migraines
Arthritis or Joint Pain
Back Pain
Hip Pain
Spinal Disc Issues/Fusion
Neck Pain
Shoulder/Arm/Hand Pain
Hip/Leg/Knee/Foot Pain
TMJ/Jaw Pain
Swollen/Stiff Joints
Broken Bones
Strains/Sprains
Scoliosis
Skin Issues
Skin Conditions
Warts
Athlete’s Foot
Rashes
Circulatory, Respiratory
Respiratory Problems
Asthma
Sinus Issues
Edema/Swelling
Blood clots
High Blood Pressure
Low Blood Pressure
Circulatory Issues
Anemia
Chest Pain
Stroke
History of Stroke in Family
Heart Problems
History of Heart Problems in Family
Vein/Artery Problems
Varicose Veins
Seizures/Convulsions
Numbness/Tingling
Miscellaneous
Contagious Illnesses or Diseases
Autoimmune Issues
Fibromyalgia
Implants: IUD’s, pacemakers, breast or dental implants
Digestive Issues
Liver problems
Kidney Issues
Diabetes (Type 1 or 2)
Cancer
Menstrual Problems
C-Section
Depression/Anxiety
Surgeries (explain below)
Injuries (explain below)
Sleep Problems

Use this box to describe any of the issues above, or to describe any other conditions or issues of concern. Explanation/dates occurred:

● By signing this form I give my consent to be treated, and understand all information provided is confidential.

● It is my responsibility to inform the therapist if there is any pain or discomfort during the session.

● It is my responsibility to inform the therapist if I would like an adjustment to the massage pressure being used.

● I understand massage and foot zones are not a substitute for medical examinations, diagnosis, or treatment. I’m aware I should see a qualified healthcare provider for any medical or mental issues I’m aware of.

● I understand that massage therapists or foot zone practitioners are not qualified to diagnose, prescribe, or treat for any physical or mental illness, and nothing said during any session should be considered as such.

● At any time, the practitioner has the right to refuse service for any reason.

● Because massage or foot zoning can be contraindicated under certain medical conditions, I affirm I have disclosed all known medical conditions, and answered all questions honestly. I agree to keep the practitioner updated on any changes to my medical profile, and understand there shall not be liability on the practitioner's part if I forget to do so.


Parent or Guardian's Email Address

Email
Check to receive information, news, and discounts by e-mail.
A signed copy of this waiver will be sent to the email address you provide.
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Is this your first massage?*
No
Yes
Do you bruise easily?*
No
Yes
Are you sensitive to smells?*
No
Yes
If female, are you pregnant?*
No
Yes

If so, how many weeks along?

List all medications you are taking:

List all allergies here:

Please read over this list carefully and check the box of any issue you have or have had: 

Muscular, Skeletal
Headaches/Migraines
Arthritis or Joint Pain
Back Pain
Hip Pain
Spinal Disc Issues/Fusion
Neck Pain
Shoulder/Arm/Hand Pain
Hip/Leg/Knee/Foot Pain
TMJ/Jaw Pain
Swollen/Stiff Joints
Broken Bones
Strains/Sprains
Scoliosis
Skin Issues
Skin Conditions
Warts
Athlete’s Foot
Rashes
Circulatory, Respiratory
Respiratory Problems
Asthma
Sinus Issues
Edema/Swelling
Blood clots
High Blood Pressure
Low Blood Pressure
Circulatory Issues
Anemia
Chest Pain
Stroke
History of Stroke in Family
Heart Problems
History of Heart Problems in Family
Vein/Artery Problems
Varicose Veins
Seizures/Convulsions
Numbness/Tingling
Miscellaneous
Contagious Illnesses or Diseases
Autoimmune Issues
Fibromyalgia
Implants: IUD’s, pacemakers, breast or dental implants
Digestive Issues
Liver problems
Kidney Issues
Diabetes (Type 1 or 2)
Cancer
Menstrual Problems
C-Section
Depression/Anxiety
Surgeries (explain below)
Injuries (explain below)
Sleep Problems

Use this box to describe any of the issues above, or to describe any other conditions or issues of concern. Explanation/dates occurred:

● By signing this form I give my consent to be treated, and understand all information provided is confidential.

● It is my responsibility to inform the therapist if there is any pain or discomfort during the session.

● It is my responsibility to inform the therapist if I would like an adjustment to the massage pressure being used.

● I understand massage and foot zones are not a substitute for medical examinations, diagnosis, or treatment. I’m aware I should see a qualified healthcare provider for any medical or mental issues I’m aware of.

● I understand that massage therapists or foot zone practitioners are not qualified to diagnose, prescribe, or treat for any physical or mental illness, and nothing said during any session should be considered as such.

● At any time, the practitioner has the right to refuse service for any reason.

● Because massage or foot zoning can be contraindicated under certain medical conditions, I affirm I have disclosed all known medical conditions, and answered all questions honestly. I agree to keep the practitioner updated on any changes to my medical profile, and understand there shall not be liability on the practitioner's part if I forget to do so.


Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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