Name

First Name

Last Name

Birth Date.

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Who referred you?

First Name

Last Name

Emergency Contact Name & Number

General focus/goals for your session(s)?

MEDICAL HISTORY

In order to plan a massage session that is safe and effective, we will need some general information about your medical history.

Are you currently under medical supervision

If Yes, please describe in detail if you see fit to go on with your sessions

What is your history of traumas/impacts physically on your body in the last 10 years (sprains, falls, car accidents, surgeries ect)?

Do you suffer from anxiety

Are you currently seeing a Chiropractor?

If Yes, how often?

What medications are you currently taking?

CONDITION(S) THAT MAY APPLY FOR YOU:

If marked any above, please write in detail information

INFORMED CONSENT & WAIVER

By Clicking "ACKNOWLEDGED" on each paragraph, I acknowledge and understand this is my verbal and electronic consent.

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 I PLEDGE TO LIVE 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(s). 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 massages or alternative therapies.

I understand that body work may be needed near my chest, groin, gluteal area, I will be draped modestly at all times and if I feel uncomfortable with receiving work in these areas, I can request to decline the work at any time during my session(s).

I understand that massage therapy and bodywork 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 or the massage, and I will be liable for full payment of the scheduled session.

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.

Any information exchanged during a massage or body work session is confidential and is only used to provide me with the best healthcare 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.

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 of the therapist’s health at risk.

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 a fourty eight (48) hours’ notice when I need to change or cancel my appointment, I agree to pay the company 50% of the initial rate for the booked appointment time. I further understand that I will be additionally charged $35.00 for any returned checks I have given to the therapist.

I understand that massage therapy and bodywork are for the purposes of stress reduction, relief from muscular tension and spasm, general relaxation and improvement of circulation and energy flow.

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

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.

I understand that manipulation of my body may cause superficial bruising and soreness after any session and that it is my responsibility to take precautionary measures before and after my session(s) to ease the recovery process (such as drinking water, stretching, getting adequate sleep, diet and so forth).

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 and checked of described conditions.

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.

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

ACKNOWLEDGEMENT SECTION.

By Electronically signing this “informed consent and waiver”, I consent to receive therapy at I Pledge to Live LLC and hereby agree to all policies of I Pledge to Live LLC, and waive and release I Pledge to Live LLC and its entire staff, massage therapists, and bodywork practitioners 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 reflexology, acupressure, energy therapy, Reiki, Thai Massage, Thai Yoga Massage, Shiaztu, Ashiaztu, aromatherapy, craniosacral therapy, myofascial release therapy, strength and condition training, yoga, among other modalities. I further undertake to indemnify and hold I Pledge to Live LLC harmless from and incident(s) arising from my use of I Pledge to Live’s services.

Date

I agree to and acknowledge the forgoing of this date

YYYY

Thank you for officially signing your life away to me! ;)

Your appointment time is your start time.

Most introductory sessions are fully clothed and on the mat (unless discussed otherwise). Bring/wear comfortable warm clothing (as your body temperature tends to drop as you relax).

Enjoy your session and be on the lookout for Gao’s follow up call/text/email!

—gn

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