Release of Liability Waiver: Massage Services

Release of Liability Waiver for Massage Services

Name

First

Last

Client History

1. Have you undergone any surgery in the last nine months? *

Yes, please specify:Yes, please specify:

No

2. Do you have, or are you recovering from any serious injuries?

Yes, please specify: Yes, please specify:

No

4. Do you exercise regularly?

Yes

No

5. Are you pregnant or trying?

Yes

No

Allergies

1. Do you have any allergies to lotions, oils or nuts?

Yes, please specifyYes, please specify

No

2. Do you have any other allergies?

Yes, please specify:Yes, please specify:

No

Medications

1. List any medications and vitamins that you take regularly.

Massage Preferences

1. What type of massage do you prefer?

Light

Medium

Deep

What area(s) do you feel tension, stiffness, or discomfort?

3. What type of massage lotion do you prefer?

4. Are you sensitive to warm therapeutic towels and warm lotion?

Yes

No

Agreements

Most client suffer no adverse side effects from massage treatments. However, side effects can include but are not limited 
to; mild redness, soreness, and mild bruising, all of which are temporary.

I understand that massage sessions are for general wellness purposes only and that I should see a doctor or other 
healthcare provider for diagnosis and treatment of any suspected medical problem. I understand that it is my responsibility 
to take care of myself at all times during the massage session. This includes taking responsibility for my emotions and body 
and that the therapist is responsible only for giving a therapeutic massage.

I understand that any attempt to engage in a discussion or touch of a sexual nature will result in the termination of the 
massage and removal from the spa. In this case I will be liable for payment in full.

Signature *

Clear

I confirm to the best of my knowledge, that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. All information on this form will be kept strictly confidential. I agree to hold Spa Escape, and its employees harmless for any and all side effects, which may result from my informed decision to receive a massage treatment. I have read and understand the above release of liability waiver and hereby give my consent to receive a massage treatment.