Name *

First Name

Last Name

Today's Date

MM

DD

YYYY

Preferred Phone Number *

(###)

###

####

Preferred form of communication

Text/Phone

Email

Emergency Phone #:

(###)

###

####

Are you pregnant

Yes

No

Have you had a fever in the last 72 hours of 100°F or above? *

Yes

No

Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath? *

Yes

No

Do you now, or have you recently had, any chills, muscle aches, new loss of taste or smell, or new rashes or lesions? *

Yes

No

Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms? *

Yes

No

Has anyone with COVID-19 or coronavirus-type symptoms been in your home the last 14 days? *

Yes

No

Consent *

I have completed this form to the best of my knowledge and will inform the therapist of any change in my physical health. It is my choice to receive bodywork therapy. I am aware of the benefits and risks of bodywork and give my consent for bodywork. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that bodywork is not a substitute for medical care, medical examination or diagnosis. I understand that a bodywork therapist can not diagnose illness, disease, or any other medical, physical, or emotional disorder. I am responsible for consulting a qualified physician for any physical ailments that I have. I understand that bodywork is a therapeutic health aide and is non-sexual. Any inappropriate behavior will not be tolerated and will be charged for the full session. I understand that my personal health information will be collected. I understand that all information that I provide will be kept confidential unless required by law. I understand and consent that my medical information may be shared by the various care providers involved in my care and treatment. I understand that if the therapist starts a session late, she will make it up to me at the end of my session if possible, or will reduce my fee accordingly. I understand that if I arrive late, my session will end at the originally scheduled time so the client following me is not penalized. I agree to give 24-hour notice for a scheduled session that I can not keep. I am aware that I will be charged the full fee for any missed sessions or for sessions that I do not give 24-hour notice to cancel or reschedule.

I Accept

I Decline