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New Client Intake and Liability Waiver

Informed Consent

• I understand that massage given to me by Andersonville Massage is for the purpose of stress reduction, pain reduction, relief from muscle tension, increased circulation, improved mobility/range of motion, rehabilitation from injury, or other reason discussed during intake. No promises or guarantees will or can be made to me about the success, outcome, or side effects of the therapy.

• I understand that the massage therapist does not diagnose illness or disease and does not prescribe medical treatment or pharmaceuticals, nor are spinal manipulations part of massage therapy. Massage therapy is not a substitute for medical care, and it is recommended that I work with my primary caregiver for any condition I may have. 

• The therapist reserves the right to refuse massage therapy on anyone that she feels has a condition for which massage is contraindicated.

• I understand that massage while under the influence of drugs and alcohol is dangerous and contraindicated.

• Draping will be followed to ensure that your breasts and genitalia are covered. Even if you choose to leave on some clothing, a sheet will be draped. Only the area being massaged will be undraped. How you choose to receive the massage is completely up to you - undress to your comfort level.

• I understand that if I experience any unusual discomfort and/or pain during my massage session it is my responsibility to inform the massage therapist so that she can adjust the pressure or technique being used. 

Policies

• Twelve hours notice is required to cancel or change any appointment. The online booking system will not allow cancellations with less than 12 hours notice. In the event of an emergency, please notify Andersonville Massage via email (amanda.gurtler.lmt@gmail.com) or call/text (224-707-0811). 

• Cancellations made with less than 12 hours notice will result in a fee equal to 50 percent of the price of your cancelled service. A no-show will result in a fee equal to the the full price of the appointment.

• If you arrive late to your appointment, time may be taken from your session to avoid penalyzing the following client. You will be charged for the full amount of the massage.

• If a client presents with signs and/or symptoms of illness that contraindicate massage (fever, undiagnosed rash, contagious infection), the session will be re-scheduled. This is to protect the health of both the client and the therapist. If you are feeling ill or are unsure if massage is appropriate, contact your therapist.

• Massage is strictly non-sexual, and Andersonville Massage has a zero tolerance policy for sexual harassment of any kind, including but not limited to solicitations for "extras", suggestive comments, or inappropriate touch. Should you choose to engage in such behavior, the session will be immediately terminated, you will be charged in full for your appointment, and you will be banned from booking further appointments.

Participant's
AdultMinor
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First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Information
Have you had a professional massage before?*
Yes
No

Please list any areas of discomfort/pain:

Please list any areas you prefer not to be worked on:

Please list any injuries and medical conditions:

Please list any allergies:
Are you pregnant? (Please note, Andersonville Massage does not currently offer prenatal massage. If you are pregnant, please call/text/email to cancel your appointment.)*
No
Yes

How did you hear about Andersonville Massage? If through a friend, please include their name.
First Client's Signature*
Client'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*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
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*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Have you had a professional massage before?*
Yes
No

Please list any areas of discomfort/pain:

Please list any areas you prefer not to be worked on:

Please list any injuries and medical conditions:

Please list any allergies:
Are you pregnant? (Please note, Andersonville Massage does not currently offer prenatal massage. If you are pregnant, please call/text/email to cancel your appointment.)*
No
Yes

How did you hear about Andersonville Massage? If through a friend, please include their name.
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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