To save you time, fill out your intake form before your first massage, by clicking on this link. If not, you can fill it out in the office, but remember to arrive 5-10 minutes early so that it doesn't eat into your massage time.

CLIENT:

By signing this “Informed Consent and Wavier”, I consent to receive therapy at Byler Bodywork LLC and hereby agree to all policies this LLC, and waive and release Byler Bodywork LLC from any and all past, present, and future liability, loss, cost, claim, or damage whatsoever which may be imposed upon the Company relating to massage therapy and bodywork; including but not limited to neuromuscular therapy, reflexology, acupressure, energy therapy, viseral manipulations, all forms of kinesiology, aromatherapy, craniosacral therapy, myofascial release therapy, trigger point therapy, stretching therapy, strength and condition training, among others.

I further undertake to indemnify and hold Byler Bodywork LLC harmless from any incident(s) arising from my use of the this LLC’s services. I agree to and acknowledge the foregoing on this day of

___________, 20___

(Date)

_____________________________________________

(Signature)

_____________________________________________

(Printed Name)

 

Are you under age 18?

□Yes □No

 

PARENT/GUARDIAN WAVIER FOR MINORS:

If the client is less than 18 years old, the Client’s parent and natural guardian hereby represents that he/she is, in fact, acting in that capacity, has consented to his/her child or ward’s availing of the services of Byler Bodywork LLC, and has agreed individually and on behalf of the child or ward, to the terms of this “Informed Consent and Wavier”. The undersigned parent or guardian further agrees to save and hold harmless and indemnify Byler Bodywork LLC from all liability, loss, cost, claim, or damage whatsoever which may be imposed upon Byler Bodywork LLC relating to massage therapy and bodywork; including but not limited to neuromuscular therapy, reflexology, acupressure, energy therapy, viseral manipulations, all forms of kinesiology, aromatherapy, craniosacral therapy, myofascial release therapy, trigger point therapy, stretching therapy, strength and condition training, among others, on

behalf of the Client and all of the Client’s parents or legal guardians. I agree to and acknowledge the foregoing on this day of

___________, 20___

(Date)

_____________________________________________

(Signature)

_____________________________________________

(Printed Name)

______________

1. I understand that massage body workers and holistic practitioners are not medical doctors and do not diagnose illness,

disease, or any physical or mental disorder. I acknowledge that massage and alternative holistic therapies are not

substitutes for medical treatment, and that Byler Bodywork LLC, “the company”, recommends I see a primary

healthcare provider for that service. I understand that it is my responsibility to communicate with my therapist if I have

concerns or questions about my session. I do not have any injuries or conditions that would prevent me from receiving a

massage, nor have I been told by a health care provider that I should not receive mas

sages or alternative therapies.

 

2. I understand that massage therapy and body work services are a therapeutic health aid and are non­‐sexual. I understand my massage therapist reserves the right to end a therapy session in the case of sexual innuendo or advances from the client. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the massage, and I will be liable for full payment of the scheduled session.

 

3. Any information exchanged during a massage or body work session is confidential and is only used to provide me with the best health care services available. I understand that a massage therapist will ask me questions about my health and

physical condition and that I am obligated to answer truthfully and honestly about my health history in full detail.

 

4. I understand that my feedback is essential in my treatment, and that if I experience any unusual discomfort and/or pain during my massage session, it is my responsibility to inform the therapist in order to enable the therapist to adjust the

pressure or technique being used.

 

5. The therapist reserves the right to decline, discontinue, or restrict services based on any provided information that may indicate that massage therapy would put my health or the therapist’s health at risk.

 

6. I acknowledge that I am responsible to be on time for my appointments and that the therapist is not under any obligation to extend my therapy session. I also agree that I am responsible to pay for the full time I have booked with the therapist if I am late. I understand that my appointment time is reserved for me only. If I miss an appointment or am unable to give twenty four (24) hours’ notice when I need to change or cancel my appointment, I agree to pay the company 30% for the booked appointment time. I further understand that I will be additionally charged $30.00 for any returned checks.  In the case of emergencies, clients can discuss with the owner forgiveness of fee.

 

7. I understand that massage therapy and body work are for the purposes of stress reduction, relief from muscular tension

and spasm, general relaxation and improvement of circulation and energy flow.

 

8. I understand that the practitioner does not prescribe medical treatment of pharmaceuticals, nor does he/she perform any spinal manipulations.

 

9. I understand that service offered today, and in the future, are not a substitute for medical care and that any information

provided to me by the therapist is purely for educational purposes and is not diagnostically prescriptive in nature.

 

10. I have stated all of my known medical conditions on the Client Intake form. I have consulted a medical doctor or licensed medical health care practitioner regarding any checked or described conditions.

 

11. I understand that it is solely my responsibility to keep the therapist updated on any changes in my

physical health and I further understand that the company and the therapist shall not be liable for any purpose and for any reason whatsoever, should I fail to do the needful as per this paragraph.

 

12. I have reviewed this form in its entirety and I have discussed all my concerns regarding my treatment with my therapist.