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Higher Elevation Healing Arts School

Client Release for Massage and Health Intake

I agree to take full responsibility for myself as I use the rooms/amenities at Higher Elevation Healing Arts facility. I give my consent to recieve massage therapy. I will not misrepresent myself to any agents/staff of Higher Elevation Healing Arts in reguards to my health status, and will communicate if and when I need to change anything about the massage session.

I Agree

I agree to the 8-hour cancellation policy, and that no shows will be charged in full

I Agree

I acknowledge that massage therapy is not a substitute for medical diagnosis and treatment.

I Agree

The following disclosures are in reference to student massages:

Students are practicing techniques and skills they are learning and may ask for instructor help during massages

I Agree

If you are not receiving an effective massage, you may ask the student to have an instructor assist

I Agree

Providing detailed feedback during and after a student massage is essential to helping our students learn and grow as therapists

I Agree

Student requests are subject to change at any time

I Agree

 

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Health Intake
What is your primary reason for seeking massage today *
Pain Reduction
Stress Relief
Athletic performance
Improved wellness
Other

List typical daily activities

List any illnesses, injuries or health concerns from the past year

Do you have any areas you would prefer to not have massaged?

Do you have any allergies we should be aware of?
Are you currently taking any of the following types of medications
Narcotic Pain relievers
Blood Thinners
Anti seizure medications
Blood Pressure medication
Do you have a preference for Massage oil/cream scents*
Unscented only
Relaxation: Lavender and Bergamot
Muscle Therapy: Pine, Arnica, Peppermint and Cedarwood
No oil/ cream or lotion only
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Health Intake
What is your primary reason for seeking massage today *
Pain Reduction
Stress Relief
Athletic performance
Improved wellness
Other

List typical daily activities

List any illnesses, injuries or health concerns from the past year

Do you have any areas you would prefer to not have massaged?

Do you have any allergies we should be aware of?
Are you currently taking any of the following types of medications
Narcotic Pain relievers
Blood Thinners
Anti seizure medications
Blood Pressure medication
Do you have a preference for Massage oil/cream scents*
Unscented only
Relaxation: Lavender and Bergamot
Muscle Therapy: Pine, Arnica, Peppermint and Cedarwood
No oil/ cream or lotion only
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Health Intake
What is your primary reason for seeking massage today *
Pain Reduction
Stress Relief
Athletic performance
Improved wellness
Other

List typical daily activities

List any illnesses, injuries or health concerns from the past year

Do you have any areas you would prefer to not have massaged?

Do you have any allergies we should be aware of?
Are you currently taking any of the following types of medications
Narcotic Pain relievers
Blood Thinners
Anti seizure medications
Blood Pressure medication
Do you have a preference for Massage oil/cream scents*
Unscented only
Relaxation: Lavender and Bergamot
Muscle Therapy: Pine, Arnica, Peppermint and Cedarwood
No oil/ cream or lotion only
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Health Intake
What is your primary reason for seeking massage today *
Pain Reduction
Stress Relief
Athletic performance
Improved wellness
Other

List typical daily activities

List any illnesses, injuries or health concerns from the past year

Do you have any areas you would prefer to not have massaged?

Do you have any allergies we should be aware of?
Are you currently taking any of the following types of medications
Narcotic Pain relievers
Blood Thinners
Anti seizure medications
Blood Pressure medication
Do you have a preference for Massage oil/cream scents*
Unscented only
Relaxation: Lavender and Bergamot
Muscle Therapy: Pine, Arnica, Peppermint and Cedarwood
No oil/ cream or lotion only
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Health Intake
What is your primary reason for seeking massage today *
Pain Reduction
Stress Relief
Athletic performance
Improved wellness
Other

List typical daily activities

List any illnesses, injuries or health concerns from the past year

Do you have any areas you would prefer to not have massaged?

Do you have any allergies we should be aware of?
Are you currently taking any of the following types of medications
Narcotic Pain relievers
Blood Thinners
Anti seizure medications
Blood Pressure medication
Do you have a preference for Massage oil/cream scents*
Unscented only
Relaxation: Lavender and Bergamot
Muscle Therapy: Pine, Arnica, Peppermint and Cedarwood
No oil/ cream or lotion only
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Health Intake
What is your primary reason for seeking massage today *
Pain Reduction
Stress Relief
Athletic performance
Improved wellness
Other

List typical daily activities

List any illnesses, injuries or health concerns from the past year

Do you have any areas you would prefer to not have massaged?

Do you have any allergies we should be aware of?
Are you currently taking any of the following types of medications
Narcotic Pain relievers
Blood Thinners
Anti seizure medications
Blood Pressure medication
Do you have a preference for Massage oil/cream scents*
Unscented only
Relaxation: Lavender and Bergamot
Muscle Therapy: Pine, Arnica, Peppermint and Cedarwood
No oil/ cream or lotion only
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Health Intake
What is your primary reason for seeking massage today *
Pain Reduction
Stress Relief
Athletic performance
Improved wellness
Other

List typical daily activities

List any illnesses, injuries or health concerns from the past year

Do you have any areas you would prefer to not have massaged?

Do you have any allergies we should be aware of?
Are you currently taking any of the following types of medications
Narcotic Pain relievers
Blood Thinners
Anti seizure medications
Blood Pressure medication
Do you have a preference for Massage oil/cream scents*
Unscented only
Relaxation: Lavender and Bergamot
Muscle Therapy: Pine, Arnica, Peppermint and Cedarwood
No oil/ cream or lotion only
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Health Intake
What is your primary reason for seeking massage today *
Pain Reduction
Stress Relief
Athletic performance
Improved wellness
Other

List typical daily activities

List any illnesses, injuries or health concerns from the past year

Do you have any areas you would prefer to not have massaged?

Do you have any allergies we should be aware of?
Are you currently taking any of the following types of medications
Narcotic Pain relievers
Blood Thinners
Anti seizure medications
Blood Pressure medication
Do you have a preference for Massage oil/cream scents*
Unscented only
Relaxation: Lavender and Bergamot
Muscle Therapy: Pine, Arnica, Peppermint and Cedarwood
No oil/ cream or lotion only
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Health Intake
What is your primary reason for seeking massage today *
Pain Reduction
Stress Relief
Athletic performance
Improved wellness
Other

List typical daily activities

List any illnesses, injuries or health concerns from the past year

Do you have any areas you would prefer to not have massaged?

Do you have any allergies we should be aware of?
Are you currently taking any of the following types of medications
Narcotic Pain relievers
Blood Thinners
Anti seizure medications
Blood Pressure medication
Do you have a preference for Massage oil/cream scents*
Unscented only
Relaxation: Lavender and Bergamot
Muscle Therapy: Pine, Arnica, Peppermint and Cedarwood
No oil/ cream or lotion only
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Health Intake
What is your primary reason for seeking massage today *
Pain Reduction
Stress Relief
Athletic performance
Improved wellness
Other

List typical daily activities

List any illnesses, injuries or health concerns from the past year

Do you have any areas you would prefer to not have massaged?

Do you have any allergies we should be aware of?
Are you currently taking any of the following types of medications
Narcotic Pain relievers
Blood Thinners
Anti seizure medications
Blood Pressure medication
Do you have a preference for Massage oil/cream scents*
Unscented only
Relaxation: Lavender and Bergamot
Muscle Therapy: Pine, Arnica, Peppermint and Cedarwood
No oil/ cream or lotion only
Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
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*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Health Intake
What is your primary reason for seeking massage today *
Pain Reduction
Stress Relief
Athletic performance
Improved wellness
Other

List typical daily activities

List any illnesses, injuries or health concerns from the past year

Do you have any areas you would prefer to not have massaged?

Do you have any allergies we should be aware of?
Are you currently taking any of the following types of medications
Narcotic Pain relievers
Blood Thinners
Anti seizure medications
Blood Pressure medication
Do you have a preference for Massage oil/cream scents*
Unscented only
Relaxation: Lavender and Bergamot
Muscle Therapy: Pine, Arnica, Peppermint and Cedarwood
No oil/ cream or lotion only
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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