BIOMOTIVES Client Health Intake/Waiver Form
This will allow us to rule out any contraindications that could prevent service.
Client's Name
*
First Name
Last Name
Phone Number
*
Email Address:
*
example@example.com
Do you have any of the following?
Accident
Neck Pain
Whiplash
Headaches.
Shoulder Pain
Upper Back Pain
Mid back pain
Lower back pain
Joint Ache
Limited Range of motion.
Broken Bones
Sprains
Seizures
Abdominal Pain
Nervous Tension
Arthritis or gout
Allergies to scents
Wear contacts
Scoliosis
Surgery
Fibromyalgia
Carpal Tunnel
Mastectomy
Breast Implants
Diabetes
Varicose Veins
High Blood Pressure
Stroke
Heart Attack
Cancer
Colitis
HIV
Other
What areas are you feeling pain or discomfort?
*
Have you had any surgery in the last 6-12 months? If so, where?
Are you taking any medications? If so, describe:
Are you pregnant?
No
2nd Trimester
3rd Trimester
Have you ever received massage therapy?
*
Yes
No
Type of massage received?
Deep Tissue
Swedish
New to massage
Other
Rate your water consumption level:
Low
1
2
3
4
High
5
1 is Low, 5 is High
Reason for treatment
*
Relieve Stress
Promote relaxation
Sleep better
Reduce muscle tension
Relieve tension headache
Enhance exercise performance
Manage Lower back pain
Help chronic neck pain
Relieve postoperative pain
Relieve osteoarthritis pain
Increase range of motion
Increase flexibility
Other
Do you have any of the following:
*
Sunburn
Severe pain
Inflammation
Headaches
Open cuts, bruises, burns
Irritated Skin Rash
Poison
Cold/Flu
COVID-19 symptoms: Fever, fatigue, dry cough, difficulty breathing, GI issues
None
By signing this waiver/liability form, I acknowledge and confirm the following:
*
I give my permission to receive message services
I acknowledge that massage therapy is not a substitute for medical care, medical examination and diagnosis.
I understand that the service provider does not diagnose illnesses or injuries, or prescribe medications.
I have stated all medical conditions that I am aware of and will inform my practitioner of any changes inmy health status. I have clearance from my physician to receive massage
I understand the risks associated with massage therapy include, but are not limited to; superficial bruises or redness, short-term muscle soreness, exacerbation to undiscovered injury.
I therefore release the service provider from all liability concerning these injuries that may occur during the massage session.
I understand the importance of informing the service provider of all medical conditions and medicationsI am taking, and to let the service provider know about any changes to these. I understand that theremay be additional risks based on my physical condition.
I understand that it is my responsibility to inform the service provider of any discomfort I may feel duringthe session so he/she may adjust accordingly.
I understand that my personal health information will be collected. I understand that all information thatI provide will be kept confidential unless required by law. I understand and consent that my personalinformation may be shared by the various care providers involved in my care and treatment.
I understand that I or the service provider may terminate the session at any point in time
I have been given a chance to ask questions about the session and my questions have been answered
Treatment Modalities:
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I give my permission to receive treatment services that includes treatment modalities. including: decompression cupping therapy, assisted stretching, compression therapy, cryotherapy, hydrotherapy, hot stones, thai massage technique, myofascial release, and infrared light therapy.
I hereby acknowledge that I have voluntarily chosen to receive decompression therapy from BIOMOTIVES. I understand and agree to the following: Decompression cupping is a therapeutic technique that involves the use of suction cups on the skin to promote relaxation and potential relief from muscle tension and discomfort. I understand that decompression cupping is not a substitute for medical treatment or diagnosis and that it is solely a wellness and relaxation modality. Risk and limitations: I am aware that decompression therapy marks and bruising on the treated areas, which is a normal and expected response.
I acknowledge that any treatment modality listed above may not be suitable or advised for any individuals with certain medical conditions, such as pregnancy, skin infections, or blood clotting disorders.
I have disclosed any relevant medical conditions or concerns to the therapist prior to any treatments using treatment modalities.
Release of Treatment Liability:
*
I release BIOMOTIVES, its therapists, employees, and representatives from any liability for any injury, discomfort, or adverse reaction that may occur as a result of: decompression cupping therapy, assisted stretching, compression therapy, cryotherapy, hydrotherapy, hot stones, thai massage technique, myofascial release, and infrared light therapy.
I understand that any treatment modality listed above is performed by a trained professional, but will communicate any discomfort or concerns during the session and follow any post-treatment instructions provided.
I acknowledge that any treatment modality listed above may not be suitable or advised for any individuals with certain medical conditions, such as pregnancy, skin infections, or blood clotting disorders.
I acknowledge that I have read and understood the contents of treatment modality waiver and freely assume all risks associated with the therapy.
Policy Notification
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Cancellation Policy: We respectfully ask that you provide us with a 24-hour notice of any schedule changes or cancellationrequest. Please understand that when you cancel or miss your appointment without providing a 24-hour notice we are often unable to fill that appointment time. This is an inconvenience to your therapist and also means our other clients miss the chance to receive services they need. For this reason, you will have to reschedule for another day. You will also forfeit points earned if you are a “no call, no show”. We understand that emergencies can arise and illnesses do occur at inopportune times. If you have a fever, a known infection, or have experienced vomiting or diarrhea within 24 hours prior to your appointment time, we request you cancel your session. Inclement weather may also result in need for late cancellations. We will do our best to give advanced notice if we are closing or need to cancel due to bad weather or illness and we ask that you do the same. Please do not risk your own safety trying to make your appointment. Late cancellation due to emergency, illness, or inclement weather will generally not result in any missed session points, but this is determined on a case-by-case basis.
Late Arrival Policy: We request that you arrive 5-10 minutes prior to your appointment time to allow time to fill out any required paperwork as well as answer any intake questions your therapist may have. We understand that issues canarise that may cause you to be late for your appointment. However, we ask that you call to inform us if this ever occurs so we can do our best to accommodate you. Appointment times are reserved for each client, so often times we cannot exceed that reserved time without making the next client late. For this reason, arriving after your appointment time may result in loss of time from your massage so that your session ends at the scheduled time. Full service fees will be charged even when sessions are shortened due to late arrival. In return we will do our best to be on time, and if we are unable to do so we will add time to your session to make up for our late arrival or adjust the service charge.
Inappropriate Behavior Policy: Massage therapy is for relaxation and therapeutic purposes only. There is absolutely no sexual component to massage whatsoever. Any insinuation, joke, gesture, conversation, or request otherwise will result in immediate termination of your session and refusal of any and all services in the future. You will be charged the full service fee regardless of the length of your session. Depending on the behavior exhibited we may also file a report with the local authorities if necessary. Treat your therapist with respect and dignity and you will be treated the same in return.
Client's Signature (Adult)
*
Parent/Guardian Signature and Consent (UNDER 18 YEARS OF AGE). I ______ authorize my specialist to perform the service on my minor.
Date Signed
*
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Month
/
Day
Year
Date
Submit
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