Massage Liability Release Form

13302 Grant Rd., Cypress, TX 77429

contact@kneadsmassage.com

Your One-Stop Destination for Massage and Skin Care Treatment We guarantee you'll be in the hands of the best esthetician and massage therapist in Houston.

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Massage Liability Release Form

1 Client Info

2 Health Information

3 Liability Release

Version: 3.0

PERSONAL INFORMATION

FIRST NAME:

LAST NAME:

CONTACT NUMBER:

GENDER: Male Female

ADDRESS:

CITY:

STATE:

ZIP CODE:

DOB:

OCCUPATION:

EMAIL:

(EMERGENCY) CONTACT NAME

EMERGENCY RELATIONSHIP

EMERGENCY CONTACT PHONE

MASSAGE NOTES

PLEASE CHECK THIS BOX IF YOU ARE PREGNANT.

HOW MANY MONTH?

ANY RISK FACTORS:

CHECK THIS BOX IF THERE ARE AREAS YOU DO NOT WANT TO BE TOUCHED.

PLEASE DESCRIBE:

CHECK THIS BOX IF YOU HAVE EVER RECEIVED PROFESSIONAL MASSAGE/BODYWORK BEFORE?

DATE:

CHECK THIS BOX IF YOU ARE IN PAIN OR DISCONFORT?

PLEASE DESCRIBE:

WHAT MAKE IT BETTER:

WHAT MAKES IT WORSE:

MASSAGE GOALS:

HEALTH INFORMATION

CHECK THIS BOX IF YOU HAVE UNDERGONE ANY SURGERIES OR MEDICAL PROCEDURES IN THE LAST 6 MONTHS?

PLEASE DESCRIBE:

CHECK THIS BOX IF YOU ARE TAKING ANY PRESCRIPTION OR OVER-THE-COUNTER?

PLEASE DESCRIBE:

CHECK THIS BOX IF YOU HAD ANY ORTHOPEDIC INJURY.

PLEASE DESCRIBE:

CHECK THIS BOX IF YOU ARE ALLERGIC TO OILS OR LOTIONS.

PLEASE DESCRIBE:

PLEASE SELECT ANY MEDICAL CONDITIONS BELOW THAT APPLIES TO YOU:

Musculo Skeletal

SPRAIN

TENDINITIS

BURSITIS

ARTHRITIS

FIBROMYALGIA

SCOLIOSIS

CARPAL TUNNEL

PLANTAR FASCIITIS

JOINT

Spine | Nerve

SCIATICA

HERNIATED DISC

DISC ISSUES

HYPERTENSION

HIGH BLOOD PRESSURE

NUMBNESS

Neuro | Head | Cardio | Metabolic | Respiratory

HEADACHES

MIGRAINES

HYPERTENSION

HIGH BLOOD PRESSURE

DIABETES

ASTHMA

ECZEMA

NEUROPATHY

KIDNEY

BLOOD CLOTS

Any Extra Medical Conditions

CANCER

HEART ATTACK

STROKE

VARICOSE VEINS

BLOOD CLOTS

NUMBNESS

By signing this form or proceeding with services, I acknowledge and agree to the following terms:

I give my voluntary consent to receive massage therapy services.
I understand that therapeutic massage is not a substitute for professional medical care, diagnosis, or treatment…
I acknowledge that the massage therapist does not diagnose medical conditions or prescribe medications.
I confirm that I have received clearance from my physician, if necessary…
I understand there are potential risks; I release Kneads Massage and its therapists from liability…
I acknowledge the importance of informing the therapist of medical conditions, allergies, medications, and changes…
I will communicate any discomfort during the session.
Either party may terminate the session at any time.
My questions have been answered.
Kneads Massage is not liable for loss/theft/damage to personal property.

By CHECKING this checkbox, I certify that I have completed this form truthfully and to the best of my knowledge…

DATE:

Work Hours

Monday, 10am - 7 pm
Tue-Fri, 9am - 7pm
Saturday, 9am - 3pm
Sunday | Closed

Massages

Swedish Massage
Deep Tissue Massage
Prenatal Massage
Cupping Therapy
Lymphatic & Post Surgery
Ultrasonic Cavitation

Skin Care

Mini Refresh Facial
Acne Rescue Facial
Age Smart Facial
Cavemen Treatment
Back Facial Treatment
Booty Glow Treatment

About Us

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CANCELATION POLICY

I truly understand that life can be unpredictable. If you need to cancel or reschedule, kindly let me know at least 24 hours in advance. This allows someone else to take the spot and ensures it's not left vacant.

If you're feeling unwell, please call as soon as you realize you won't make your appointment as a courtesy to others.

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