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Massage/Reflexology Acknowledgement and Waiver
Have you had massage or reflexology before?
*
Yes
No
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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.
*
*
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What is your main complaint?
*
Have you had implants within the past 9 months? (Cheek, chin, breast, pectoral, calf, etc.)
*
Yes
No
Please check any of the following medical conditions/symptoms that you have experienced in the last year:
*
Heart Disease
High Blood Pressure
Hospitalization
Hepatitis
Sciatica
Stroke
Whiplash
Asthma
Cellulitis/Phlebitis/Thrombosis
Fibromyalgia
Disc Problems
Insomnia
Migraines
Contagious Disease
Pregnancy
Herpes Simplex
Carpal Tunnel
Arthritis
Immunity Related Disorder
Diabetes
Respiratory Condition
Varicose Veins
Fever
Skin Lesions or Abscesses
Kidney or Liver Disorder
Scoliosis or Lordosis
Lumbar Spinal Stenosis/Spondylitis/Spondylolisthesis
Irritable Bowel Syndrome
Hemorrhoids
None
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.
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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.
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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.
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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.
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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
*
First
Last
Address
*
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City
State
Zip Code
Country
Phone Number
*
Email
*
Today's Date
*
Choose Any
*
I am 18 years of age or older.
Acceptance of Agreement
*
I accept this agreement.
Submit
About
Appointment Info
Facility
Services
Floating
>
Floating Benefits
Floating FAQ
How to Float
For Women Only
7 Theories of Floating
Magnesium
Sanitation
History of Floating
Athletes
Reflections
Research
Reflexology
Shiatsu
Hydromassage
Steam
Pricing
Book Now
Gift Cards
Videos
Contact
COVID-19