Chicago Healing Massage Intake Form

Chicago Healing Massage : Health Intake & Waiver Form

All information is held in strict confidence.
At no point is information disclosed or shared without the client's written consent.

Name*

First NameLast Name

Appointment Date

Date

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Mobile Phone Number

Area CodePhone Number

Mobile Phone Number*

Birth Date*

Date

Occupation

HEALTH HISTORY

For your safety, Massage Therapists must be aware of any history regarding any of the following conditions. Therapeutic massage may affect these conditions and your health. Please take a moment to fill in any of the conditions that may apply and make appropriate notes. It is always important to share with your therapist every surgery, injury, and medication you have received including if you are sick or are starting to feel sick to ensure there are no adverse reactions.

Please list any areas of focus or information relevant to your session you would like to include.*

Surgeries, Injuries, Accidents*

Allergies, Skin Sensitivities or Infectious Conditions *

Cardiovascular*

Any Medications That May Relate to Massage

If applicable, please let me know if you are pregnant

...

MASSAGE POLICIES

Your appointment time is reserved especially for you. If you are unable to keep your appointment please contact us 24 hours in advance or you will be charged for the full value of your service.

By providing my email above I agree to receive occasional emails. I understand I may unsubscribe or change my email preferences at anytime.

Payment is due at the time of service. I accept cash, credit card or check as well as
Venmo: @SarahWeinstock1
Zelle: 773-517-5485

Client services and chart information are confidential. Written authorization is required from you to release any information.

Please silence your cell phone for optimal relaxation.

You will have a consultation with Sarah to discuss your session.

Should the session require, after your massage therapist has left the room, you may disrobe to your comfort level.

You will be draped appropriately at all times.

I understand that Sarah or I may end the session at any time for any reason.

Inappropriate behavior will not be tolerated and may be prosecuted.

CLIENT AGREEMENT

I understand that massage therapy is for the purpose of stress reduction, relief from muscular tension, general relaxation and improvement of circulation.

I understand that at any time I feel discomfort or pain, I will inform Sarah so they may adjust accordingly.

I also understand that Sarah does not diagnose any illness, disease, physical or mental disorders; does not prescribe medical treatments or pharmaceuticals, nor do they perform any spinal manipulations.

Massage therapy is not a substitute for medical treatment or diagnosis, and is recommended that I see a physician for physical ailments.

I have stated all my known medical conditions and understand it is my responsibility to keep Sarah updated on any changes in my health so that they may make any appropriate adjustments to our sessions.

I agree that Sarah Weinstock, and all their agents, contractors, employees, representatives, executors, insurers, and all others acting on their behalf as well as any buildings, and/or property will not be held liable for any and all claims or liabilites for injuries or damages to my person and/or property that may arise during or as a result of this or any future massage therapy sessions.

Ashiatsu Massage:
By nature of the technique, I understand the increased risk of injury to my person when receiving Ashiatsu Oriental Bar Therapy. I understand that I may be receiving deep tissue techniques during the massage therapy sessions and that, as a result of these techniques, I put myself at risk for injuries.

In addition, if I request a higher level of pressure than that of the therapeutic range the massage therapist is providing I will be responsible for aggravating any condition that may already be present. With this in mind, I agree that the massage therapist, and all their agents, contractors, employees, representatives, executors, insurers, and all others acting on their behalf as well as any buildings and/or property will not be held liable for any and all claims or liabilities for injuries or damages to my person and/or property that may arise during or as a of result of this or any future massage therapy sessions.

Coronavirus/COVID-19:
The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is contagious and is believed to spread mainly from person-to-person contact. Sarah Weinstock has put in place preventive measures to reduce the spread of COVID-19. However Sarah Weinstock cannot guarantee that you will not become infected with COVID-19.

Assumption of Risk: By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19, and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury, illness, damage, loss, claim, liability, or expense, of any kind, that I may incur.

Waiver of Liability: I hereby release, covenant not to sue, discharge, and hold harmless Sarah Weinstock from all liabilities, claims, actions, damages, costs, or expenses of any kind arising out of or relating to COVID-19.

Signature

All information is held in strict confidence. At no point is information disclosed or shared without the client's written consent.

All information is held in strict confidence.
At no point is information disclosed or shared without the client's written consent.