Traditional Old Style Hawaiian Massage Consult Form

Have you been exposed to covid-19 or have any symptoms such as fever, cough, sore throat or shortness of breath? *

Have you received any covid-19 injections within the past 12 weeks? *

Name*

Date of birth*

Home Address*

Email*

example@example.com

Phone*

Occupation

How did you hear about me?

Have you experienced a professional massage previously?

Do you have any areas of concern or soreness?*

Do you have any of the following conditions? If so, please provide further details below.

Please provide any further details:

A Lomi Lomi treatment traditionally attends to the whole body, head to toe to fingertips (with the exception of genitalia If you have any concerns please discuss them prior to the commencement of your massage.

I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular & emotional tension. When I experience any pain or discomfort during the session, if necessary, I will inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment. I understand that Lomi Lomi Practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Massage should not be performed under certain medical conditions, as such, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile prior to the session and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that the practitioner reserves the right to refuse to perform massage on anyone whom he/she deems to have a condition for which massage is contraindicated.

Release and Indemnity to the Lomi Lomi Practitioner:

IN CONSIDERATION of my payment for participating in the activity provided by Sonje Rosie (and the extent that the same may be precluded by statute) I ACKNOWLEDGE AND AGREE TO RELEASE AND INDEMNIFY the Lomi Lomi Practitioner as follows:

1.I participate in the activity at my own risk and responsibility. 2.I release, indemnify and hold harmless the Lomi Lomi Practitioner from and against all actions or claims that may be made by me or on my behalf by other parties in respect of or occurring from an injury, loss, damage, or death caused to me or my property whether from negligence, breach of contract or in any way whatsoever or any liability that results from the breach of an express or applied warrant that the treatment will be rendered with responsible care or skill. 3.In the event that I am injured or my property damaged, there will bring no claim, legal or otherwise, against the Lomi Lomi Practitioner in respect of the injury or death. By signing this document, I acknowledge that I have read and understood all content and know that it affects my legal rights.

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Date*

Date

Traditional Old Style Hawaiian Massage

General & Medical Information

You are unable to continue with this booking until you no longer have symptoms of coronavirus (covid-19) or a minimum of 12 weeks have passed since your last covid-19 injection.