Lisa Jean C.M.T
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Pre and Postnatal Care
Home
Contact
About
Services/Prices
Kind Words
Pre and Postnatal Care
Intake and Consent
Name
*
First
Last
Birthday
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Phone Number
*
-
-
Email
*
Occupation
*
Emergency Contact
*
Have you had a professional massage before
*
yes
no
if so, when was your last?
*
How would you describe your stress life
*
Whats stress
Homeopathic doses
Managable
Regularly feel it in my body as pain or discomfort
Difficult to relax
I eat stress for every meal
Are you currently working on yourself with other professionals
*
Please list any injuries, accidents, surgeries, or traumatic events
*
If you're dealing with chronic pain or illness, please describe
*
List any medications you are taking (including self prescribed)
*
What physical activities do you participate in regularly?
*
walkin/hiking
yoga
pilates
running
weight training
List all known allergies
*
Are you currently pregnant
*
yes
no
If yes, how far along are you
*
Is there anything else you want me to know
*
I understand that the massage/bodywork I receive from Lisa Souza is provided for the purpose of relaxation, relief of muscular tension, increased range of motion and overall well being. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage or bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage/ bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I assume full responsibility for receipt of massage therapy; I release and discharge the practitioner from any and all claims, liability, damages, actions or causes of actions arising from therapy received. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.
I understand payment is due at completion of scheduled appointment. I agree to give 12hrs notice to Lisa Souza if I need to cancel or I will pay 100% of appointment costs.
I understand that this consent form and waiver of liability will apply to my current and future therapy sessions with Lisa Souza.
I consent to receive massage and bodywork from Lisa Souza (sign name here)
*
Submit
EMAIL ADDRESS
makeritual@gmail.com
TELEPHONE NUMBER
408.425.6775
PHYSICAL ADDRESS
1478A Church Street
San Francisco, CA. 94131
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