Massage/Reflexology

Massage/Reflexology Acknowledgement and Waiver

Have you had massage or reflexology before? *

Yes No

Do you wear dentures? *

Yes No

Are you taking any blood-clotting medication? *

Yes No

Are you taking any blood-thinning medication? *

Yes No

Are you taking any pain-killers, cancer medication or muscle relaxants? *

Yes No

Do you have a tendency to bruise easily? *

Yes No

Have you recently been exposed to a communicable disease? *

Yes No

Do you have any recent injuries? *

Yes No

Have you had any surgeries within the past 5 years? *

Yes No

Are you pregnant or trying to conceive? If pregnant, please put due date below. *

Yes No

If you answered yes to any of these, please explain. *

* Indicates required field

What is your main complaint? *

Have you had implants within the past 9 months? (Cheek, chin, breast, pectoral, calf, etc.) *

Yes No

If you answered yes to any of these, please describe. *

Please take a moment to read and initial the following information:

I understand that massage/reflexology is provided for stress reduction, relaxation, improved nerve messsages, and improvement of circulation and energy flow. *

If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure can be adjusted to my level of comfort. I will not hold my therapist responsible for any pain or discomfort I experience during or after the session. *

I understand that the services offered today are not a substitute for medical care. I understand that my therapist is not qualified to diagnose, prescribe, or treat physical or mental illness. *

I affirm that I have notified my therapist of all known medical conditions and injuries. *

I agree to inform the therapist of any changes in my health and medical condition. I understand that there shall be no liability on the therapist’s part should I forget to do so. *

By signing this release, I hereby waive and release my therapist from any and all liability, past, present, and future relating to massage/reflexology and bodywork. *

In exchange for receiving Services from Metta Relaxation Co., I, for myself and on behalf of my heirs, executors, administrators and personal representatives, hereby waive, release, discharge and hold harmless Metta Relaxation Co. its members, officers, employees and agents from any and all liability for any and all injuries, including death, damages or claims relating to or resulting from my receipt of the Services, now or in the future, foreseen or unforeseen. Further, I will indemnify and hold Metta Relaxation Co., its members, officers, agents and employees, harmless from and against any and all claims, rights, damages, liabilities, losses, costs and expenses (including reasonable attorneys’ fees) arising from or in connection with any injuries to other persons or damage to property caused by or attributed to me. *

Cancellation Policy: 24 hours notice is required to avoid being charged for the service.

ELECTRONIC ACCEPTANCE.
By entering your information below, you are accepting the acknowledgement and waiver agreement.

Name *

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I am 18 years of age or older.

Acceptance of Agreement *

I accept this agreement.

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