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Patrick Good LMP

Release of Liability & Current Condtions 

Please read and sign

I verify that all information is correct and current to the best of my knowledge. I understand that any information provided is for safety purposes and will be kept strictly confidential.

I hereby give my consent to receive massage services and/or other bodywork or treatment (“Services”) Patrick Good LMP, and I acknowledge and agree that I am doing so at my own risk. My health and safety with respect to such Services are my sole responsibility. I acknowledge that my receipt of the Services from Patrick Good, LMP may result in bodily injury to me or my death. My decision to receive Services from Patrick Good, LMP is voluntary, and I know of, understand and assume any and all the risks associated therewith.

In exchange for receiving Services from Patrick Good, LMP, I, for myself and on behalf of my heirs, executors, administrators and personal representatives, hereby waive, release, discharge and hold harmless Patrick Good LMP, its members, officers, employees and agents from any and all liability for any and all injuries, including death, damages or claims relating to or resulting from my receipt of the Services, now or in the future, foreseen or unforeseen. Further, I will indemnify and hold Patrick Good, LMP, its members, officers, agents and employees, harmless from and against any and all claims, rights, damages, liabilities, losses, costs and expenses (including reasonable attorneys’ fees) arising from or in connection with any injuries to other persons or damage to property caused by or attributed to me.

I acknowledge that I have read, and understand, the release and indemnification provisions set forth in the preceding paragraph, and agree to such terms.

  • I understand that massage therapy is provided for stress reduction, relaxation, relief from muscular tension, and improvement of circulation and energy flow.
  • If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/strokes can be adjusted to my level of comfort. I will not hold my therapist responsible for any pain or discomfort I experience during or after the session.
  • I understand that bruising or flu-like symptoms may occur after treatment.
  • I understand that the services offered today are not a substitute for medical care. I understand that my therapist is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness.
  • I affirm that I have notified my therapist of all known medical conditions and injuries.
  • I agree to inform the therapist of any changes in my health and medical condition. I understand that there shall be no liability on the therapist’s part should I forget to do so.
  • I understand that massage is entirely therapeutic and non-sexual in nature.
  • By signing this release, I hereby waive and release my therapist from any and all liability, past, present, and future relating to massage therapy and bodywork.
  • I have received the policy statement, and have read and agree to the policies therein.

I have been shown and agree to the HIPPAA Form

Please select who will be participating
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First Clients's Name

First Name*

Middle Name

Last Name*

Phone*
First Clients's Date of Birth*
First Clients's Signature*
Clients'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 or Guardian's Email Address

Email*

Confirm Email*
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Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Health Information
Please check whether or not you currently have or have had any of the following conditions:
"Please use the space below to provide additional information concerning those items checked or any other health-related conditions you currently have or have had in the past."
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.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's 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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