HOAG Agreement & Intake Form

Massage Therapy Service Agreement & Intake Form
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Are you currently seeing a Chiropractor, Physical Therapist, or Physician for an ongoing issue?*

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Consent for Therapy and Waiver of Liability
The undersigned (“Client”) hereby freely consents to receipt of massage services from:

Ngozi Onuma
Licensed Massage Therapist

Client agrees as follows:
1. Client understands and agrees that they will provide the Therapist with complete and accurate health information, and a written referral from Client’s primary healthcare provider if Client is currently receiving care or has a specific medical condition or symptoms for which Client takes medication or receives periodic evaluations or treatment. Client understands that massage therapy is designed to be an ancillary health aid and is not suitable for primary medical treatment for any condition. Client and Therapist have discussed the potential benefits and possible side effects of massage therapy and have agreed upon a course of focused attention and manually therapy for the predetermined goals of stress reduction, relief of muscular discomfort, and/or promotion of general health. Client has been given an opportunity to ask questions of the Therapist and has received all requested information.
2. Client understands that the unclothed body will be draped at all times for warmth, sense of security, and as a mark of massage therapy professionalism. Client agrees to immediately inform the Therapist of any unusual sensation or discomfort so that the application of pressure may be adjusted to Client’s level of comfort. Client understands that massage therapy is not sexual in any manner and that any illicit or suggestive remarks or behavior on the client’s part, will result in an immediate termination of the therapy session. Client understands that payment will be expected in full; regardless if the massage is completed or not.
3. Client hereby assumes fully responsibility for receipt of the massage therapy, and releases and discharges Therapist from any and all claims, liabilities, damages, actions, or causes of action arising from the therapy received hereunder, including, without limitation, any damages arising from acts of active or passive negligence on the part of the Therapist , to the fullest extent allowed by law.
4. Client understands that each appointment time is designated for Client and agrees to be prepared to start session at appointment time or forfeit the time that they are not.
5. Client, in signing this consent for Therapy and Waiver of Liability (“Consent”), understands and agrees that this Consent will apply to and govern the current and all future therapy sessions performed by Therapist
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Massage Therapy Service Agreement & Intake Form

Check any of the following conditions that apply to you, past and present. Please add your comments at the end to clarify the conditions you checked.

Consent for Therapy and Waiver of Liability