Reflections Yoga and Wellness

Massage Intake

**Please answer the questions below

** Please select any of the following conditions you may have.

Massage Waiver of Liability and Consent

By E-signing this form, you agree to the following:

• I understand my consent for massage

  is informed and voluntary and I may withdraw my consent at any time except for actions already taken.

  
  

• I understand that I or the massage practioner may terminate the session at any time.

• I release the massage practitioner and Reflections Yoga and Wellness LLC from all liability for any harm that may unintentionally result from any massage treatment.

I understand that massage is for the purpose of overall well-being, relaxation, stress reduction, relief from muscular tension or spasm, or for increasing circulation. I understand that the massage practioner at Reflections Yoga and Wellness LLC does not diagnose illness, disease or any other physical or mental disorder. The massage pracitioner does not prescribe medical treatment nor perfom spinal manipulations. I will inform the practitioner of my current condition at the time of each visit. I acknowledge that long term imbalances and or tension in the body sometimes require multiple sessions.