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

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Session Type

If you chose Combo Session please specify here. For example: 60 minutes Swedish Relaxation Massage & 30 minutes Reiki. ***Must be a combo/duration that is listed on the website***

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

Date

Today's Date (if different from Session Date)

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