Name
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First Name
Last Name
Date of Birth
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DD
YYYY
Email Address
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Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone number
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Occupation
Emergency Contact Name
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Emergency Contact Number
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Current or Previous Major Illnesses
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Current or Previous Injuries or Accidents
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Medical History
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Please tick any that apply
Pregnancy
Are you currently under the care of a consultant? If so why?
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Are you currently taking any medications? Please list.
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Purpose/reason for today's visit
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Are you allergic to any nuts or oils?
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Do you have any areas of discomfort and pain?
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If yes how long for?
Have you sought out any other therapies or treatments?
What do you think is causing your injury or pain?
Do you exercise regularly? List type and frequency.
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Massage Therapy Acknowledgement
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Focused attention and manual therapy will be given as agreed upon by the massage therapist and client for the predetermined goals of stress reduction, relief of muscular discomfort, and or health promotion. I understand that the massage therapist is not a licensed physician or chiropractor.
I will immediately inform my massage therapist of any unusual sensation or discomfort, so that the application of pressure of strokes/technique(s) may be adjusted to my level of comfort, and agree to disclose any physical limitations, disabilities, ailments, or impairments, which may affect my ability to receive soft tissue therapy and massage services.
I understand that there is no implied or stated guarantee of success or effectiveness with massage therapy treatments.
I understand that by signing this form, I give my consent to receive the massage therapy treatments discussed in the initial and all future sessions and agree that my presence at subsequent sessions shall be construed to be continuation of this written consent.
Also, by signing this form, I hereby release Kate Campbell and any therapist providing services through Kate Campbell Fitness from any and all liability relating to soft tissue therapy and massage services received.
I have read and agree to Kate Campbell Fitness fee schedule.
Liability Waiver and Release: By signing below, the client acknowledges that they are aware of their own health and physical condition. Having such knowledge, the client further acknowledges that they are voluntarily receiving soft tissue therapy and massage services from Kate Campbell Fitness and hereby assumes all risks connected therewith and consent to receive such therapy and services.
The client also hereby releases and holds harmless Kate Campbell Fitness, its massage therapists, Staff, and of any liability, loss, cost, damage, expense, claim, or suit whatsoever for any or all injury, loss, illness, harm, cost, expense, claim, suit, damage or other claim resulting from, related to, or in any way arising from my receipt of soft tissue therapy and massage services.
IN NO EVENT WILL Kate Campbell Fitness BE LIABLE FOR CONSEQUENTIAL OR INCIDENTAL DAMAGES INCLUDING, WITHOUT LIMITATION, ANY CLAIM OR DEMAND AGAINST THE CLIENT BY ANY OTHER PARTY DUE TO ANY CAUSE WHATSOEVER, EVEN IF THE CLIENT HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES. KATE CAMPBELL FITNESS LIABILITY HEREUNDER, REGARDLESS OF THE FORM OF ACTION, SHALL NOT EXCEED THE TOTAL AMOUNT PAID FOR SERVICES UNDER THIS AGREEMENT, WHICH SHALL BE THE CLIENT'S SOLE AND EXCLUSIVE REMEDY.
The client understands that the owner of and agent for any property where soft tissue therapy and massage services are provided will be third party beneficiaries of this Liability Waiver and Release.
This Liability Waiver and Release shall be effective as of the client’s acceptance below, shall remain in effect for all future sessions with Kate Campbell Fitness and shall survive termination of client’s receipt of services from Kate Campbell Fitness.
COVID -19
By ticking this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that you may be exposed to or infected by COVID-19 by attending Kate Campbell Fitness and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at Kate Campbell Fitness may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Kate Campbell Fitness employees, volunteers, and programme participants and their families.
I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with my attendance at Kate Campbell Fitness. On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless Kate Campbell Fitness employees, Freelance instructors and self-employed personal trainers, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of Kate Campbell Fitness, its employees, Freelance instructors and self-employed personal trainers agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any Kate Campbell Fitness programme.
Terms and Conditions
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I have read and agreed to the terms and conditions (available in the page footer)