VioLet Go Embodywork
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Name
Address
Phone Number
E-mail
Date of Birth
Occupation
Emergency Contact Name and Phone
Are you currently under a physician’s care for an acute or chronic illness and/or pain?
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If yes please explain:
If yes, who is your health care provider
Are you currently taking any prescribed medication or dietary supplements?
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If yes please explain
Have you received therapeutic bodywork before?
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If yes when and how often?
How did you hear about me
What are your goals/intentions for this session:
Please list areas of tension, stress and/or pain you wish to be addressed:
Please list any recent injuries, conditions or surgeries within the past 5 years:
Please list your stress-reduction activities, hobbies, exercise:

I have stated all conditions that I am aware of and this information is true and accurate to the best of my knowledge. I will inform my health care provider and massage therapist if anything changes in my status. I understand that massage/bodywork I receive is for the purpose of stress reduction and the relief from muscular tension, spasm or pain and to increase circulation. If I experience any pain or discomfort, I will immediately inform my massage therapist so that the pressure and/or methods can be adjusted to my comfort level. I understand that my massage therapist does not diagnose illness or disease, nor perform any spinal manipulations, and does not prescribe any medications/treatments. I acknowledge that massage is not a substitute for a medical examination or diagnosis and that I should see my health care provider for those services. If I am unable to attend my scheduled appointment, I will respect and abide by the set cancellation policies. Sexual advances, request for sexual favors, and other verbal or physical conduct of a sexual nature will constitute as sexual harassment and will not be tolerated. I understand that I am receiving massage therapy at my own risk. In the event that I become injured either directly or indirectly as a result, in whole or in part, of the aforesaid massage therapy I hereby hold harmless and indemnify the therapist, their principals, and agents from all claims and liability whatsoever.


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