Bodywork Release Form

Bodywork Release Form
Name*

First NameLast Name
Name of Parent or Guardian if recipient is under 19 years of age

First NameLast Name
Recipient Date of Birth*

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Session Type*

Swedish Relaxation MassageEuropean Lymphatic Drainage MassageAcupressure MassageLomi Lomi Massage (Ladies Only)Table ShiatsuReflexologyThai Foot MassageReikiCrystal ReikiChakra BalancingHot Stone Massage (not available during events)Aromatherapy Massage (not available during events unless permission has been obtained in advance)Combo Session (please specify below)Foot Reflexology & Head/Neck/Shoulders Massage ComboKids Mini Massage (Spa Party)
If you chose Combo please specify here. For example: 60 minutes Swedish Relaxation Massage & 30 minutes Reiki.
Please list any current health condition(s) that the practitioner needs to be aware of in order to make the appropriate adjustments to treatment(s) that you are receiving. For example; allergies, scent sensitivities, varicose veins, cuts, burns or bruises, rashes, contagious dermatological conditions, pregnancy, or any recent surgeries, etc.
What is your desired outcome for your session?
By signing below, I agree to the following; I acknowledge that massage and other bodywork modalities should not be conducted under certain health conditions and accept that I am physically and emotionally comfortable enough to receive a massage session. I also agree that if I feel any pain or discomfort during the massage session, it is my sole responsibility to inform the practitioner. I also, will take full responsibility for my body and behavior and consent to release Refresh Bodywork and/or Jennifer Reiter of any claims or injuries associated with my massage/bodywork session.
Date of Session or Massage Event*

MonthDayYear
Date
Today's Date (if different from Session Date)

MonthDayYear
Signature of recipient, or parent/guardian if under age 19.*

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