Massage Intake Form

Hot Stone Massage Release Form
Hot Stone Massage Contraindications

Hot stone massage is not suitable for everyone. There are risks associated with performing hot stone massage on individuals with the following conditions.

You must inform your massage therapist/practitioner if you have any of the following conditions which may make hot stone massage contraindicated or may require your therapist/practitioner to alter the massage.
- Pregnancy
- Diabetes
- Inflammatory skin conditions
- Open wounds or sores
- Hypotension or Hypertension
- Cancer (with or without treatment)
- Varicose veins
- Under the influence of drugs or alcohol
Client Release
I, * have read and understand the aforementioned conditions which make hot stone massage contraindicated. The massage therapist/practitioner has discussed this information with me and provided an opportunity for any questions. I have disclosed any and all health risk factors
Please check the following that applies to you.*

I understand the information contained on this form and confirm that I do not have any of the above conditions.
My condition(s) of is/are listed above and therefore make(s) hot stone massage contraindicated. Given this knowledge I hereby give my full consent to receive hot stone massage and take full responsibility of any side effects or harm that may come from my receiving hot stone massage.
I understand that I will be receiving hot stone massage as an adjunct form of healthcare only and that this therapy is not meant to replace appropriate medical care. I release the massage therapist/practitioner of any and all liability for any harm that may unintentionally occur during my treatment(s).
Signature*

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Date*

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Photo Release Form
I hereby authorize Camellia Alise, LLC and its agents and employees to photograph and film for the purpose of education, publication, promotion, illustration, advertising, or trade, in any manner or in any medium and release Camellia Alise, LLC and its legal representatives for all claims and liability relating to said images or video.

Furthermore, I grant permission to use my statements that given during an interview or testimonial, with or without my name, for the purpose of advertising and publicity without restriction. I waive my right to any compensation.

By signing below I acknowledge I have read and understand this release.
Event Description
Print Name*

First NameLast Name
Please sign or select option 2
Signature

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I decline to have my images used for promotion but understand images may be taken for medical history and progress tracking only

I agree
Date*

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Date
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Massage Intake Form

Personal Information

Medical Information

Hot Stone Massage Release Form

Client Release

Photo Release Form

Please sign or select option 2