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Health Intake/Waiver Form for Bodywork

First name

Last name

Email

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

Birthday

Month

Day

Year

Emergency Contact Name

Emergency Contact Phone Number

Medical History

Do you have any of the following conditions? Please select all that apply to your current or past medical history.

Please list all of your surgeries

Please list all of your medications

Include prescription medications, over-the-counter drugs, vitamins, and supplements.

Do you have any allergies or sensitivities?

Include allergies to medications, oils, lotions, or other substances we might use during treatment.

Please describe your pain or discomfort including when it started, what might have caused it, and what makes it better or worse.

Have you received massage therapy before?

Yes, regularly

Yes, occasionally

Yes, but not recently

No, this is my first time

What type of pressure do you prefer?

Light pressure

Medium pressure

Firm pressure

Not sure

Is there anything else we should know? Please share any additional information that might help us provide better care.

How did you hear about us?

I understand that massage therapy is for relaxation and therapeutic purposes and is not a substitute for medical diagnosis or treatment.

I have disclosed all known medical conditions and medications. I will update my therapist of any changes to my health status.

I understand that massage therapy services are strictly professional and therapeutic. Any inappropriate sexual conduct or remarks will result in immediate session termination, and I agree to pay the full appointment fee.

By signing this release, I hereby waive and release my therapist and Kula Heart Yoga & Wellness, LLC from any and all liability, past, present, and future relating to massage therapy and bodywork.

I understand that I may end the session at any time and will communicate my comfort level with pressure and techniques used.

I understand that if I am late to my appointment. Additional time may NOT be added to the session, and full payment is required.

If I do not show up for my appointment 100% of payment may be required. I understand payment is required at time of booking

By signing this document, I acknowledge the inherent risks and voluntarily assume full responsibility for any injury, damage, or loss that may result from my participation. I hereby waive and release the business, its owners, and its staff from any and all liability, past, present, and future, relating to the services provided.

Signature

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Date

Month

Day

Year

Health Intake/Waiver Form for Bodywork

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Health Intake/Waiver Form for Bodywork

1. Subscribe for Emails below 2. Create a Log-In at the top Right Corner and become a Kula Heart Member 3. Download the Fit by Wix App for your phone

Join us on mobile!

1. Subscribe for Emails below
2. Create a Log-In at the top Right Corner and become a Kula Heart Member
3. Download the Fit by Wix App for your phone