Thai Yoga Massage and Private Yoga Sessions

Thai Yoga Massage and Private Yoga Sessions

Massage Consent & Liability Waiver Form

Please initial each statement then sign and date below.

_____I have discussed with the Thai Yoga Practioner the nature and purpose of Therapeutic Thai Yoga Massage and other related procedures.

_____It is my choice to receive Thai Yoga Massage Therapy and/or Private Yoga Sessions. I realize that the treatment is being given for the well-being of my body and mind. I understand that massage/body work are for the purposes of stress reduction; relief from muscular tension, spasm, and pain; general relaxation; and for improvement of circulation and balance of energy flow. I understand that results will vary depending on the individual and the extent of his/her condition. It is the client’s responsibility to notify the practitioner immediately if the client should feel their well-being is being compromised in any way.

_____I understand that Thai Yoga Practioners and Yoga Teachers do not diagnose illness, disease, or any physical or mental disorder; nor do they prescribe medical treatment. It has been made very clear that Thai Yoga Massage and Private Yoga Sessions are not substitutes for medical examinations or diagnosis. It is recommended that I see my primary health care provider for exams and diagnosis of ailments I may have. The practitioner does not prescribe medical treatment of pharmaceuticals, nor does he/she perform any spinal manipulations. Any information offered by the practioner is for educational purposes only.
_____I have stated all of my known medical conditions on the Intake Form. I have consulted a medical doctor or licensed medical health care practitioner regarding any checked or described conditions.
_____I realize it is solely my responsibility to keep the bodywork practitioner updated on any changes in my physical health and I understand that the practitioner shall not be liable should I fail to do so.
_____I understand that all massage/ bodywork offered is strictly non-sexual. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.

_____By signing this release, I hereby waive and release Melissa Smith, the Thai Yoga Practitioner, from any and all liability, past, present, and future relating to massage and bodywork.

I have read the above and have had the opportunity to ask questions about the content.

Client Name: ______

Client Signature: ______Date: ______

Thai Yoga Massage and Private Yoga Sessions

Intake Form

Please fill out completely and sign below.

Name:______DOB: ______
Address: ______

Email: ______Phone: ______

Emergency Contact:______Emergency Contact Phone: ______

Please check off any of the following conditions or symptoms, which apply to you now or in the past:
___ High Blood Pressure ___ Blood Clots ___ Heart Attack/Stroke

___ Low Blood Pressure ___ Varicose Veins ___ Muscle Strain/Sprain
___ Low Back Pain ___ Arthritis ___ Hypo/Hyperglycemia

___ Varicose Veins ___ Osteoporosis ___ Diabetes
___ Headaches ___Cancer ___Allergies: smells/lotions
___Broken Bones ___Surgery ___ Skin Infections or Diseases
Please explain any of the above or other conditions/symptoms you have experienced: If you have had any serious or chronic illness, operations, or traumatic accidents, please explain:
Are you now, or is there any chance that you may be, pregnant? ___Yes ___No
Signature:______Date:______