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In the State of Washington, I am a healthcare professional and for your safety, the following fields are to be filled out completely and truthfully.

*Minors will need this intake completed by a parent/guardian. A minor release form will also need to be signed in person by the parent/guardian. 

INFORMED CONSENT & POLICIES

BY SIGNING BELOW, YOU ACKNOWLEDGE AND AGREE TO THE FOLLOWING:

Therapeutic massage is not a substitute for traditional medical treatment or medications and the massage therapist does not diagnose illnesses and injuries or prescribe medications. You have clearance from your physician to receive massage therapy and give your permission to receive it. You will also inform your massage therapist of all medical conditions, allergies, and medications and will update them if there are any changes. You understand there may be additional risks based on your physical condition. The risks associated with massage therapy (such as cupping, gua sha, Ashiatsu, hot stones, deep tissue, etc.) include, but are not limited to, superficial bruising, short-term muscle soreness, burns, & exacerbation of undiscovered injury; as well as any miscarriages, early labor, and other pregnancy complications that could occur during or after prenatal massage. You therefore release Vita Nova Massage PLLC and Antonietta Ramirez, LMT, and Owner from all liability concerning these injuries that may occur during the session. It is your responsibility to inform the massage therapist of any discomfort you may feel during the massage session, so they may adjust accordingly. At any time, you or the massage therapist may terminate the session. Throughout the service, the massage therapist will always use a drape, meaning a blanket and sheet, for your security and modesty.

There is no genital massage or perineal massage (massaging the tissues between the anus and genitals) and any illicit or sexual innuendos or advances will result in termination of the session and you will be liable for full payment of the session. To keep professional boundaries set by the law, the massage therapist does not fraternize or date their clients. All communication between you and the massage therapist, such as conversation during sessions, phone calls, texts, letters, or e-mails is confidential within constraints of the law. This also applies to any session documentation and intake forms, which will always be secured. You also give permission for the massage therapist to contact your emergency contact(s) in case of an emergency.

Vita Nova Massage PLLC charges a 100% cancellation fee for appointments rescheduled or cancelled without 24 hours notice and for no call/no shows. Please respect your massage therapist's time and the supplies and utilities used to prepare for your session. 

 

 

 

COVID-19 OFFICE PROTOCOLS

BY SIGNING BELOW, YOU AGREE TO FOLLOW THESE PROTOCOLS:

  1. Temperatures will be checked with a contact-less thermometer to screen for Covid-19. Any high temperatures, recent travel, or other Covid-19 symptoms being displayed will require the session to be rescheduled. 
  2. Hands will need to be washed before entering the massage studio. 
  3. A Covid-19 waiver/notice will need to be signed before every session. 
  4. Masks are required to be worn throughout the whole session for safety and liability purposes. No mask, no service, no exceptions. Facial massages are suspended until further notice. 
  5. No guests are allowed in the waiting areas or massage studio and appointments will be staggered by an hour, so no back-to-back sessions with friends or family. This is to ensure your massage therapist has adequate time to air out the room and to thoroughly complete cleaning/sanitizing protocols set by the CDC, OSHA, and DOH. 

 

Please select who will be receiving massage therapy...
AdultMinor
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First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Intake

Please list any health conditions, recent surgeries, and medications that could be affected by massage therapy. If you are currently pregnant, describe here. *

Please list any allergies/sensitivities: (Such as essential oils, avocado, mango, coconut oil, shea nut oil, arnica, etc.) *

Please list any areas to avoid: (Such as the face, scalp, feet) *

Pressure Preference: Do you have a high pain tolerance and want very firm to deep pressure or light-medium? Or do you prefer light pressure on your legs and firmer pressure on your back, etc. If you're not sure, don't worry, we'll figure it out during the session. *

Describe your goals/focus areas and list any favorite modalities or techniques. *
Do you want your glutes/hips massaged? *
No
Do you want the work under the sheet "skin to skin contact"?
Do you want the work over the sheet?
Do you want abdominal massage? *
No
Do you want the work under the sheet "skin to skin contact"?
Do you want the work over the sheet?
Do you want your adductors "inner thighs" massaged? *
No
Do you want the work under the sheet "skin to skin contact"?
Do you want the work over the sheet?
I am not trained to perform breast work, but you have the option to leave your breasts uncovered. This question applies to all genders. *
keep breasts covered throughout the session
keep breasts uncovered throughout the session
keep breasts covered during chest work
keep breasts uncovered during chest work
keep breasts covered during abdominal work
keep breasts uncovered during abdominal work
Do you want your massage therapist to wear gloves during the session?*
No
Yes
Do you want your massage therapist to wear a face shield during neck and scalp work?*
No
Yes
First Client's Signature*
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*
Communication Preferences
Does your healthcare provider have permission to contact you regarding your health information and appointments via (required to select at least one): *
Email
Phone Calls
Voicemails
Text messaging
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 Intake

Please list any health conditions, recent surgeries, and medications that could be affected by massage therapy. If you are currently pregnant, describe here. *

Please list any allergies/sensitivities: (Such as essential oils, avocado, mango, coconut oil, shea nut oil, arnica, etc.) *

Please list any areas to avoid: (Such as the face, scalp, feet) *

Pressure Preference: Do you have a high pain tolerance and want very firm to deep pressure or light-medium? Or do you prefer light pressure on your legs and firmer pressure on your back, etc. If you're not sure, don't worry, we'll figure it out during the session. *

Describe your goals/focus areas and list any favorite modalities or techniques. *
Do you want your glutes/hips massaged? *
No
Do you want the work under the sheet "skin to skin contact"?
Do you want the work over the sheet?
Do you want abdominal massage? *
No
Do you want the work under the sheet "skin to skin contact"?
Do you want the work over the sheet?
Do you want your adductors "inner thighs" massaged? *
No
Do you want the work under the sheet "skin to skin contact"?
Do you want the work over the sheet?
I am not trained to perform breast work, but you have the option to leave your breasts uncovered. This question applies to all genders. *
keep breasts covered throughout the session
keep breasts uncovered throughout the session
keep breasts covered during chest work
keep breasts uncovered during chest work
keep breasts covered during abdominal work
keep breasts uncovered during abdominal work
Do you want your massage therapist to wear gloves during the session?*
No
Yes
Do you want your massage therapist to wear a face shield during neck and scalp work?*
No
Yes
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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