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.

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.

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.

CLIENT WAIVER 

 

Ashiatsu Massage:

By nature of the technique, I understand the increased risk of injury to my person when receiving Ashiatsu 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. I will tell my provider if I am feeling discomfort or need to recieve less pressure.

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.

 

Waiver of Liability: 

I hereby release, covenant not to sue, discharge, and hold harmless Sarah Weinstock, Chicago Healing Massage, Erik Marthaler and Lateral Fitness and associated entities from all liabilities, claims, actions, damages, costs, or expenses of any kind.