Client Intake Form
Client services and chart information are confidential. Written authorization is required from you to release any information.
- Please turn off your cell phone for optimal relaxation
- Your scheduled session is set aside for you.
- Due to the cleaning time needed between sessions,
please reschedule your session if you are more than 10 minutes late.
- 24 hour cancellation notice is required.
- You will be draped and at no time will genitalia or breast tissue be exposed
- You will have a consultation with your therapist to discuss your session
- Should the session require, after your therapist has left the room, you may disrobe to your comfort level.
- I understand that my therapeutic massage therapist or I may end the session at any time for any reason.
- Inappropriate behavior will not be tolerated and may be prosecuted to the full extent of the law. This includes jokes or comments of any type of sexual or inappropriate kind.
COVID-19 Informed Consent:
I understand that COVID-19 is highly contagious and still present in the community where I am seeking massage therapy. I understand that COVID19 is passed through close contact with others and that people without symptoms may be infectious. I understand that Soul Center Massage and Bodywork has taken every precaution to ensure my health and safety, but that risk of infection is still possible HIGH-RISK CLIENT.
I understand that the health conditions listed below place me at higher risk for serious COVID-19 infection. If I have one of these conditions, I should forgo massage therapy while COVID-19 is still present in my community or obtain my physician’s consent.
Should I decide to proceed with massage therapy I assume all risks related to COVID-19 infection.
The CDC estimates that 88% of people who require hospitalization for COVID-19 have one or more of these underlying conditions:
* People 65 years or older
* People who live in a nursing home or long-term care facility
* Chronic lung diseases
* Moderate to severe asthma
* Cardiovascular conditions
* Compromised or suppressed immunity
* Severe obesity (BMI 30 or higher)
* Diabetes (Type 1 or 2)
* Chronic kidney diseases undergoing dialysis
* Liver diseases
We believe clients with these conditions should consult with their primary care physician before receiving massage.
By signing above, I agree to all of the following statements:
____ have not a temperature of 100.4 F or higher in the past 72 hours.
____I have not any cold or flu-like symptoms (fever, cough, shortness of breath) in the past 14 days.
____I have not knowingly been in contact with anyone diagnosed with COVID-19 in the past 14 days.
____I have not been outside of the state (PA) or the U.S. in the past 14 days.
____In the event I contract COVID-19, I will inform my therapist as soon as possible.
Massage Liability Waiver
By my (digital) signature above, I the undersigned, herein referred to as “I” acknowledge that I have agreed to receive one or more massage therapy sessions from Michelle Levinski, herein referred to as “the therapist”. I understand that:
- As a client, I may reasonably expect to receive the general benefits of massage therapy, such as relaxation, reduction in muscle tension, and an increase in range of motion.
- The therapist has not made any guarantees or promises regarding the results of this process upon me, and any relief of physical or emotional symptoms is coincidental to the process and is not a goal of these sessions.
- Massage therapy is not involved with the treatment of disease, illness or disorders of any kind, nor does it substitute for medical diagnosis or treatment when such attention is needed. Likewise, the therapist shall not diagnose or treat any illness, disease, or other physical or mental disorder of the person; and nothing said or done to me by the therapist should be construed as such.
- I am responsible for obtaining medical clearance from my healthcare provider(s) if I have a currently diagnosed medical condition that could be a contraindication for massage therapy. I shall provide written documentation to the therapist from my provider. This includes pregnancy.
- The therapist has the right to decline to provide care or to terminate a session at any time,and for any reason.
- It is necessary for the therapist to touch and observe my body in order to conduct this process. I am aware that massage work is performed directly on the skin with the use of lubricants, and that all areas of my body not being massaged will remain draped. I give the therapist full permission to work on my body in such a way. I acknowledge that I also have the right to decline treatment to any part of my body, and to request modifications to the session plan at any time.
- In my role as a Client, it is my responsibility to:
- Arrive for massage sessions on time.
- Maintain good personal hygiene and avoid the use of perfumes, other strong scents or tobacco products before a massage session.
- Give the therapist at least 24 hours notice if I need to change or cancel a session appointment.
- Provide accurate information on my health status on the forms provided, and keep the therapist updated as to changes in my health status upon return visits including my COVID-19 symptom status.
- Provide the therapist with feedback on their massage work both during and after sessions, as requested.