Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email Address
*
Phone number
*
Emergency Contact Name
*
Emergency Contact Number
Occupation
Current or Previous Major Illnesses
*
Current or Previous injuries or accidents
*
Are you under the care of a consultant? If yes, why?
*
Are you currently taking any medications? If yes, please list
*
Medical professional/doctor
*
Medical professional/doctor phone number
*
My due date is
MM
DD
YYYY
Number of previous pregnancies
Number of previous births
Number of weeks pregnant
Tick any which apply to you or have in the past
Are you breastfeeding?
Are you experiencing any post-birth complications?
Anything else you would like to know?
Tick to show you agree with the following terms and conditions
*
I have completed this health form to the best of my knowledge. I understand that Massage is a health aid and does not take the place of a Medical Professionals care.
Any information exchanged during a Massage session is confidential and is only used to provide you with the best health care services.
If I am not able to make a scheduled appointment, I agree to cancel the appointment 24 hours in advance. If I miss a scheduled appointment without giving 24 notice, I agree pay any missed appointment charge.
I have read and agreed to the terms and conditions (link in the footer of this page)
Massage Therapy Acknowledgement
*
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 signature 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.