Hasbrouck House Massage Waivers

Ahead of your massage appointment, please fill out the following two forms, our Massage Intake Form and Massage Therapy Client Information & Waiver / Release Form, which can be found below. An additional Prenatal Massage Form is required for all prenatal massages.

Please Note: Page must be reloaded between each form submission.

MASSAGE INTAKE FORM

MASSAGE THERAPY CLIENT INFORMATION & WAIVER / RELEASE FORM
Consent for Therapy and Waiver of Liability

Name

First Name

Last Name

Client agrees as follows:

Client understands and agrees that they will provide the Therapist with complete and accurate health information and a written referral from Client’s primary healthcare provider if Client is currently receiving care or has a specific medical condition or symptoms for which Client takes medication or receives periodic evaluations or treatment. Client understands that massage therapy is designed to be an ancillary health aid and is not suitable for primary medical treatment for any condition. Client and Therapist have discussed the potential benefits and possible side effects of massage therapy and have agreed upon a course of focused attention and manual therapy for the predetermined goals of stress reduction, relief of muscular discomfort, and/or promotion of general health. Client has been given an opportunity to ask questions of the Therapist and has received all requested information. Client understands that the unclothed body will be draped at all times for warmth, sense of security, and as a mark of massage therapy professionalism. Client agrees to immediately inform the Therapist of any unusual sensation or discomfort so that the application of pressure may be adjusted to Client’s level of comfort. Client understands that massage therapy is not sexual in any manner and that any illicit or suggestive remarks or behavior on the client’s part, will result in an immediate termination of the therapy session. Client understands that payment will be expected in full; regardless if the massage is completed or not. Client hereby assumes full responsibility for receipt of the massage therapy, and releases and discharges Therapist and Hasbrouck House, LLC from any and all claims, liabilities, damages, actions, or causes of action arising from the therapy received hereunder, including, without limitation, any damages arising from acts of active or passive negligence on the part of the Therapist, to the fullest extent allowed by law. Client, in signing this consent for Therapy and Waiver of Liability (“Consent”), understands and agrees that this Consent will apply to and govern the current and all future therapy sessions performed by Therapist.

PRENATAL MASSAGE FORM
Please fill out this form only if you are scheduling a prenatal massage.

Name

First Name

Last Name

Prenatal Massage Contraindications

Massage therapy during pregnancy has been shown to be beneficial for a number of common complaints such as fatigue, musculoskeletal pain, sciatica, edema, and many others. However, there are risks associated with specific conditions that may occur during pregnancy. You must inform your massage therapist/practitioner if you have or have had in the past any of the following conditions or symptoms which may make massage therapy during pregnancy contraindicated or may require your therapist/practitioner to alter the massage. • History of miscarriage • Preeclampsia • Gestational Diabetes • History of any high-risk pregnancy • Cardiac, pulmonary, liver, or renal disorders • Drug exposure • Mother’s age under 20 or over 35 • Multiples • Pitting edema • Hypertension • Epilepsy or other convulsive disorders • Genetic abnormalities • Placental or cervical dysfunction • Fetal growth retardation • Abdominal pain • Bloody discharge • Leaking of amniotic fluid • Sudden weight gain • Fever • Diarrhea • Sudden edema/swelling • Decrease in fetal movement over 24-hour period • Severe headaches • Severe nausea or vomiting Please let us know if you have had any of the above conditions or symptoms.

Client's Release

I have read the aforementioned conditions and symptoms which make massage therapy during pregnancy contraindicated. The massage therapist/practitioner has discussed this information with me and provided opportunity for any questions. I have disclosed all high-risk factors of my pregnancy. I have discussed with my prenatal healthcare provider/physician any health concerns that I had about receiving massage therapy. I agree that my healthcare provider/physician has given me clearance to receive massage therapy. I understand the information contained on this form and confirm that: (1) I am receiving medical care including regular check-ups with a licensed healthcare provider. (2) I have not experienced any of the listed symptoms, conditions, or complications. (3) I am not currently experiencing any of the listed symptoms, conditions, or complications. (4) I am experiencing a low-risk pregnancy. I understand that I will be receiving massage therapy as an adjunct form of healthcare only and that this therapy is not meant to replace appropriate medical care. I release the massage therapist/practitioner of all liability for any harm that may unintentionally occur during my treatment(s).