Emergency contact name and phone number

Referred By

Are you currently taking any medications? If yes, please list:

Any allergies? (oils, lotions, nuts, fruits, skin, etc.) If yes, please list:

Are you pregnant? If yes, how many months and due date

Are you you currently under medical supervision or receiving other medical interventions? If yes, please describe:

Have you undergone any surgeries? If yes, please list which one(s) and date:

Areas of broken skin? (e.g.rash, wounds). If yes, where?

History of joint replacement surgery? Which joint(s)?

Recent injuries or medical procedures in the past 2 years? Please describe:

Please describe any other injuries or health conditions:

Reason for seeking treatment today:

By signing below, I acknowledge that I am aware of the benefits and risks of massage therapy and that I have completed this form to the best of my knowledge. I also agree to inform my massage therapist of any health or medical changes.

LIABILITY WAIVER AND RELEASE OF CLAIMS FOR MASSAGE SERVICES

1. Acknowledgment of Risk

I, the undersigned, acknowledge and understand that receiving massage therapy may involve certain risks, including but not limited to physical discomfort, emotional release, and potential injury. I understand that it is my responsibility to inform the therapist of any medical conditions, injuries, or contraindications that may affect my ability to receive massage therapy.

2. Release of Liability

In consideration of being permitted to receive massage therapy from Schwartz Sports Massage and its affiliates, I hereby release, waive, discharge, and hold harmless Schwartz Sports Massage, its owners, employees, and agents from any and all liability, claims, demands, or causes of action that may arise out of or relate to any injuries, damages, or losses that I may sustain while receiving massage therapy, whether caused by the negligence of the released parties or otherwise.

3. Indemnification

I agree to indemnify and hold harmless Schwartz Sports Massage from any claims, actions, damages, or losses that may arise from my participation in massage therapy, including any claims brought by third parties.

4. Medical Conditions

I certify that I have disclosed all medical conditions, injuries, or limitations to my massage therapist prior to receiving services and understand that it is essential for my therapist to know this information. I agree to notify the therapist of any changes in my health prior to receiving treatment.

5. Consent to Treatment

I consent to receive massage therapy and understand that I have the right to refuse treatment at any time. I have read and understood the above waiver and release of liability and voluntarily agree to its terms. I understand that massage is entirely therapeutic and non-sexual in nature. I understand that, because massage therapy work involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/strokes 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 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.

6. Cancellation Rescheduling Policy

If I am not able to make a scheduled appointment, I agree to cancel or reschedule the appointment at least 24 hours in advance. I agree to pay 50% of the full session rate if I give less than 24 hours’ notice. I agree to pay the full session rate if I give 2 hours’ notice or less, or if I miss an appointment without giving notice. If within 24 hours of my session, I develop a contagious illness or have a sudden, unplanned health or personal emergency rendering me unable to make my appointment, I will inform Amanda right away, and if you are unable to fill my vacancy, I will pay the cancellation fee, or session fee (if less than 2 hours notice), unless an exception is granted, only at the discretion of Schwartz Sports Massage.

7. Governing Law

This waiver and release of liability shall be governed by the laws of the State of California.

8. Photography/videography

As part of our commitment to providing high-quality care and for educational and promotional purposes, we sometimes take photographs or record videos during treatment sessions. These images or videos may be used on our website, social media platforms, or in other promotional materials. Please indicate your consent by checking the appropriate box below:

[ ] I consent to being photographed or filmed during my treatment sessions. I understand that these images or videos may be used for educational and promotional purposes.

Therapist Name: ___________________________________

Therapist Signature: ___________________________________

Date: ___________________________________