Massage By Mari Client Intake Form

359 Putnam Pike, Ste 107 Smithfield RI

401-335-0980

Client Intake Form

All information is held strictest confidence. At no given point is information disclosed or shared without client’s written consent. You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose.
Full Name*

First NameMiddle NameLast Name
Today's Date*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date

MonthDayYear
Phone Number*
This is my:
E-mail*
example@example.com
Refereed by
Emergency Contact*
Phone Number*
Occupation
Medications
Allergies
If your coming for a COUPLES MASSAGE what is your guests name?*
This is for form matching, if your a single write SINGLE
Is this your first professional massage? If not how many? How often?*
Do you have any specific problem areas you would like worked on?
Any accidents, injuries, hospitalizations or surgeries within the past year?
Do you have any fungal infections?*
Do you have any chronic pain? If so where?
Do you currently have open wounds, cuts, scabs, scrapes, or lesions? (If undisclosed session can be stopped immediately)*
Are you pregnant?*
Nut allergy?*

YesNo
Would you like our deals and specials emailed?
Write Yes if interested in future emails
The above information is accurate. I understand that massage therapists do not diagnose disease or prescribe drugs. They are not a substitute for medical care. I agree to alert my practitioner of any physical or emotional changes if any occur during our treatment.*

AgreeDisagree
I understand that an appointment must be cancelled or rescheduled with at least a 24 notice in order for there not to be a fee assessed. Should this not be the case the fee will be $35 for a single session and $50 for a couple.*

AgreeDisagree
Signature*

Clear
Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.

COVID-19 Updates and Protocols

To our amazing clients…We want to sincerely thank you for your patience during this challenging situation. The health, safety and well-being of our clients, staff and community are of the utmost importance to us. We have been working hard preparing for our reopening on Tuesday, June 23, 2020. Needless to say, we are so excited to get back to work and treat our clients.

We know our clients expect the highest standards at Massage by Mari and we are committed to providing that even during this challenging time. As the world around us has changed over the past months here is a brief, friendly reminder of all of our new procedures in the office to help keep you and our team safe. Please read them carefully.

Client protocols:

· Staff will ask all clients some appropriate screening questions and provide further information on new protocols when arriving at our office.

· Each client will be asked to sign a Covid-19 Waiver Form when arriving at our office.

· We are asking all clients to be prepared to bring and wear a mask at all times while inside our office.

· Staff will take the clients temperature.

· Clients must wash hands before the start of their appointment.

· Only clients receiving a service will be allowed in the office.

· No more than 6 clients and guests will be allowed in the office at any one time.

· Each treatment room and massage tables will be sanitized and/or disinfected between each client.

· Guests of clients will be asked to wait outside the office during the client’s appointment

· We cannot accommodate walk in appointments at any time. Please call to schedule your appointment.

A few other safety changes and additions:

· All Massage by Mari staff will be wearing masks in the office.

· We will have hand sanitizer in the reception area and other places in the office for you to use as needed.

· Appointments will be managed to allow for social distancing between clients. This may mean that you will be offered fewer options for scheduling your appointment than usual.

· Our office will be disinfected at multiple time a day, between shifts and at the end of the evening.

Thank you for your continued patience and understanding.

Assumption of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing.Massage by Mari has put in place preventative measures to reduce the spread of COVID-19; however, Massage by Mari cannot guarantee that you will not become infected with COVID-19. Further, visiting the Massage by Mari office could increase your risk of contracting COVID-19.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 by visiting the Massage by Mari office and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 by visiting the Massage by Mari office may result from the actions, omissions, or negligence of myself and others, including, but not limited to Massage by Mari staff and employees.I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with my visit to the Massage by Mari office (“Claims”). On my behalf, I hereby release, covenant not to sue, discharge, and hold harmless Massage by Mari, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of Massage by Mari, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after any visit to the Massage by Mari office.*
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