New Client Intake Form
*You may request a paper version of this form upon arriving at your appointment if you do not wish to use an E-Signature*
Massage Release Waiver
Please read the following and sign:
- I understand that my massage therapist does not diagnose illness, disease, or any physical or mental disorder. It has been made clear that massage therapy and bodywork are not substitutes for medical examination or diagnosis, and that it is recommended that I see a medical practitioner for any physical ailment I may have.
- By signing this release, I agree to waive my massage therapist and Body Harmony Massage Therapy from any and all liability, past, present, and future, relating to the massage therapy and bodywork that I receive.
- I understand that any injury to myself or damage to my personal property at the location of 166 Kamehameha Ave Hilo, HI 96720 Is my responsibility, and not that of the property owner, the establishment, or my body work practitioner.
- I understand that all massage therapy and bodywork offered is strictly non-sexual. I understand that my therapist/practitioner has the right to end a session due to inappropriate conduct.
Confedential Massage Intake Form
Please check any recent or chronic medical conditions you may have and discuss them before the treatment begins.
If you have a condition that is not listed, please provide additional information on the line marked “other”.
Informed Consent & Liability Wavier
- My temperature has not been above 98.6°F in the past 72 hrs
- I have not knowingly been in contact with anyone diagnosed with Covid-19 in the past 2 weeks.
- I have not had any of the following symptoms in the past 2 weeks:
Fever, Cough, Shortness of Breath, Persistent Chest Pain or Pressure.
- I have not traveled to or from the Big Island of Hawaii in the past 14 days
*If the answer to the above question is Yes, please provide proof of secondary covid-19 test negative result
- I acknowledge I am receiving Massage Therapy knowing that social distancing cannot be adhered to during my
- In the event I contract Covid-19, I will notify my therapist as soon as possible.
COVID-19 has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing. Your Massage Therapist has put in place preventative measures to reduce the spread of COVID-19; however, your massage therapist cannot guarantee that you will not become infected with COVID-19. By signing this agreement, I acknowledge the contagious nature of COVID19 and voluntarily assume the present and future risk that I may be exposed to or infected by COVID-19 by receiving massage therapy and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with my massage therapy appointment. On my behalf, I hereby release, covenant not to sue, discharge, and hold harmless my massage therapist, their massage establishment, and any interested parties from the Claims, including all liabilities, claims, actions, damages, costs, or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of my massage therapist or the establishment where massage therapy services are received, whether a COVID-19 infection occurs before, during, or after participation in any massage therapy session.
- During the current outbreak, the safety of our staff and clients is very important to us.
- We are staggering our appointments so that only one client and massage therapist will be in our reception area at a time.
- Please do not bring anyone with you to your appointment, and do not arrive prior to your allotted time so we can fully disinfect the clinic between clients.
- We have stepped up our hygiene protocols and will be wearing masks during our sessions.
- In addition, we are asking all clients to wear a mask while in our office and during your massage (you may remove
your mask when lying face-down).