CONFIDENTIAL CLIENT INFORMATION & HEALTH HISTORY
Massage Therapy includes the assessment and treatment of the soft tissues and joints of the body, using soft tissue manipulation, joint mobilization.
This record of consent is required before the first assessment or treatment and will be maintained confidentially in the client file.
By signing below, the client agrees to the following:
All massage treatments, information and records will be kept confidential and securely stored for use only by the massage therapist.
Written consent must be given by me prior to any disclosure or sharing of my personal and clinical information with any third party, unless subpoena is handed.
Privacy will be assured as I have the right to undress only to my comfort level and according to the requirements of the treatment.
Draping will be used by the therapist as required to expose only those parts of my body that require treatment and/or as I choose to ensure my comfort during treatment.
I understand that I need to inform my therapist of any specific requests and changes on my health prior to entry in the room every time I come in to get a massage, as it may change from the first time I fill this form to the next appointment.
If at any time during the treatment, I feel uncomfortable with the treatment for any reason, I have the right to request an immediate stop to the session or request modifications to the treatment, regardless of prior consent given. If massage is stopped on the first 15 minutes no charge will apply; if even I dislike the service, but received it in full, fees will be due as expected.
Promptness is expected for all appointments. In the event of lateness, the massage may be cut short due to the therapist other commitments. Fees will be maintained per the schedule.
Fees for treatment are due prior to departure on the day of the treatment. Cash or credit cards are accepted. Cancellation of any appointment must be received at least 24 hours in advance. No show, same day or last-minute cancelation will be liable to full fee payment, which will be charged on the credit card or gift certificate on file.
The therapist may refuse to treat any client or part of their body with just and reasonable cause.
Disclaimer
The above information is accurate and true to the best of my knowledge. I understand that massage therapist does not diagnose disease, prescribe medication or manipulate bones. I further understand that massage therapy is not a substitute for medical attention or examination. Because massage therapy should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I take responsibility for alerting my practitioner to any physical, mental or emotional changes that occur with my health and understand that shall be no liability on the practitioner's part should I forgot to do so.
It is also understood that any illicit or sexual suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of scheduled appointment. I, also, understand that cancelled or missed appointments without 24hours notice (medical emergencies excluded) may be charged in full to my credit card on file for the price of missed session.
Date: 11/7/2020
Time: 4:18 PM
CLIENT INFORMED CONSENT ABOUT COVID-19
I understand that close contact with people increases the risk of infection from COVID-19. By signing this form, I acknowledge that I am aware of the risks involved and give consent to receive massage from this practitioner.
Date: 11/7/2020
Time: 4:18 PM
CLIENT CONSENT TO SHARE INFORMATION WITH HEALTH DEPARTMENT
I understand that my name and contact information might be shared with the state health department in the event that a client or practitioner at this facility tests positive for COVID-19. My contact details will only be shared in the event they are relevant based on suspected exposure date, and only for appropriate follow-up by the health department.
Date: 11/7/2020
Time: 4:18 PM
CLIENTS AT HIGH RISK
Unless otherwise directed by the client’s primary healthcare provider, clients at higher risk of severe illness from COVID-19 should forgo massage while the virus is present in their communities.
CDC indicates that these underlying conditions place people at higher risk for severe illness from COVID-19:
People 65 years or older, Chronic lung disease, Moderate to severe asthma, Heart conditions, Compromised or suppressed immunity, Severe obesity (body mass index of 40 or higher), Diabetes, Chronic kidney disease, Liver disease
I understand that as a person categorized as high risk, I should not get a massage at this time unless directed by my doctor. But if I still decide to go ahead and receive the massage, I assume that is my responsibility and decision on this action. Moreover, I’ll release Magna Facility Management, Inc (dba Just Massage Studio) and the massage therapist that provided the service of any wrong doing if I contract COVID-19.