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Liability Release: I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during the session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment. I understand that massage therapists 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 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 massage therapist updated as to any changes in my medical profile during the session and understand that I shall assume all liability for damages sustained as a result of my failure to provide the massage therapist with any changes. I understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session and/or loss of massage service privileges. I also understand that the Licensed Massage Therapist reserves the right to refuse to perform massage on anyone who he/she deems to have a condition for which massage is contraindicated. 

First Participant's Name
First Name*
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Parent or Guardian's Email Address
Email
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
Other
Every client must check the first box. NYSHIP insurance clients must check all 3 boxes.
All clients - I will be considered a no-show if I am more than 10 minutes late without giving notification and the full charge will apply. Refunds are the discretion of management.
NYSHIP Insurance Clients - A valid credit card is required to be on file at all times in the event that NYSHIP denies your massage claim. FMT New Windsor LLC will attempt all re-submissions and appeals with NYSHIP if your claim is denied. A charge of $135 per massage will apply if after all appeals we can not collect payment from NYSHIP.
NYSHIP Insurance Clients - You agree to use a minimum of 6 massages in the calendar year or a fee ranging from $100-$600 may be charged.
If you have NYSHIP, upload your script here.
  
Valid file types: JPG, GIF, PNG, and PDF
If you have NYSHIP enter your policy number (9 digits top of card)
If you have NYSHIP enter your group number (7 digits bottom right of card)
If you have NYSHIP, you are the:
If you have NYSHIP, do you see another massage therapist, acupuncturist or chiropractor that takes your NYSHIP insurance? *
No
Yes
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Relationship*
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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