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MASSAGE
INTAKE FORM
Gender

MEDICAL HISTORY

Are You Curetly Taking Any Medcations
Are You Currently Pregnant
Do You Have History of Any of the Following Conditions
Have You Had Any Surgery in the past 3 months
Do you have any allergies including fragrances, lotions, latex or oils
Do you have any of the following symptoms
Have you had COVID-19 in the past two months

SESSION DETAILS

Have you had professional massage before
How much pressure do you prefer
Areas you would like your therapists to focus on
Areas you would like your therapists to avoid

CLIENT CONSENT

AlternaH takes your privacy seriously. For the safety of clients, AlternaH maintains records for any health or medical conditions which may indicate that a particular service or treatment should not proceed. (eg: allergies, pregnancy, skin conditions) or a particular product should not be used (eg: products containing nuts, fish oils etc). These health records are not used for any other purpose. Client records are held securely and can only be seen by members of AlternaH.

If you have a medical condition or certain health symptoms, massage therapy may be problematic for you. AlternaH reserves the right to refuse to provide massage therapy services to you and/or require a referral from your primary health care provider prior to massage services being provided. Please remember that you are in a professional setting with a professional therapist, and do not expect anything other than therapeutic massage and natural healing treatment.

LIABILITY WAIVER

I understand that the Massage Services are for the purposes of stress reduction, pain reduction, and relief from muscle tension. If at any point during the Massage Service, I am uncomfortable or uneasy with the treatment being administered and/or if I experience pain, I understand and hereby agree that it is my responsibility to IMMEDIATELY inform the massage therapist, so that the massage therapist may modify massage strokes and pressure to a level of comfort and/or terminate the Massage Service, if appropriate. I understand that AlternaH does not diagnose illness or disease, or any other disorder, and that AlternaH and its massage therapists do not prescribe or provide medical treatment, pharmaceuticals, spinal manipulations, or chiropractic procedures as part of the Massage Services I understand that Massage Services are not a substitute for medical examinations or medical care, and that it is recommended that I work with and seek the advice of my primary caregiver for any condition I may have. I have stated all of my known physical conditions, medical conditions, and medications to AlternaH, and I will keep AlternaH and my massage therapist updated on any changes. I give my consent for any Massage Services provided on the signature date of this document and for any future and past massage therapy sessions.  I have read this document and hereby freely give my permission to be massaged and acknowledge and agree that I am doing so at my own risk. My health and safety with respect to all Massage Services are my sole responsibility. I acknowledge that my receipt of the Massage Services from AlternaH may result in bodily injury to me. My decision to receive Massage Services from AlternaH is voluntary, and I know, understand and assume any and all risks associated therewith.By signing this document and in exchange for receiving Massage Services and Natural Healing treatment from AlternaH, I, for myself and on behalf of my heirs, executors, administrators and personal representatives, hereby waive, release, discharge AlternaH, its members , employees, and agents from any and all liability for any and all injuries, including death, damages, or claims relating to or resulting from the receipt of the Massage Services and Natural Healing treatment, now or in the future, foreseen or unforeseen. Further, I will indemnify and hold AlternaH, its members, officers, agents, and employees, harmless from and against any and all causes of action, claims, rights, demands, 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 in connection with my receipt of Massage Services and Natural Healing Treatment. This liability waiver and release extends to AlternaH together with owners, partners, and employees.

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