Name *

First Name

Last Name

Phone *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birthday *

MM

DD

YYYY

Please select 1-3 areas you would like to primarily focus on during your session. *

Neck

Shoulders

Back

Glutes

Hamstrings

Calves

Knees

Quadriceps

Hips

Abdominal

Pecs

Arms

Hands

Face

Jaw

Please indicate any of the following that apply to you. *

Cancer

Headaches/ Migraines

Arthritis

Diabetes

Joint Replacement (s)

High/ Low Blood Pressure

Neuropathy

Fibromyalgia

Stroke

Heart Attack

Kidney Dysfunction

Blood Clots

Numbness

Sprains or Strains

NONE

Have you experienced any of the following symptoms in the last 14 days? If yes, we ask that you reschedule our appointment in two weeks. *

Fever

Sore Throat & Painful Swallowing

Nasal Congestion

Runny Nose

Headache

Fatigue

Shortness of Breath

Cough

Chills

Loss of sense of smell

Loss of Appetite

NONE

Are you pregnant? If yes, how many weeks/ months? Pregnant clients may only receive massage after 12 weeks.

Yes

No

I understand that all the modalities provided by Body Compass LLC is not a replacement for medical care and that no medical diagnosis will be made. Because massage, bodywork, energy work, biomagnetism therapy may be contraindicated due to certain medical conditions, I affirm that I have informed the therapist of all known medical conditions and will keep the therapist updated as to any changes in my medical condition going forward. If I experience any pain or discomfort during the session, I will immediately inform the therapist so that the pressure and/or manipulations, draping or environment may be adjusted to my level of comfort. *

I agree

36 HOUR CANCELLATION - Should I cancel or miss an appointment with less than 36 hours notice, I authorize Body Compass LLC to charge my VISA/MC/Amex/Discover Card or checking account for the 50% of the session fee. *

I agree

LATE POLICY - I will arrive to my appointment on time or 10 min earlier. If I am running late, I will call or text to let the therapist know. I acknowledge that I am only guaranteed my scheduled time. The therapist is not obligated to give me the full session if it is my fault I am late. *

I agree

COVID-19 has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing. Your Massage Therapist has put in place preventative measures to reduce the spread of COVID-19; however, your massage therapist cannot guarantee that you will not become infected with COVID-19. By signing this agreement, I acknowledge the contagious nature of COVID- 19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19 by receiving massage therapy and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with my massage therapy appointment. On my behalf I hereby release, covenant not to sue, discharge, and hold harmless my massage therapist, their massage establishment, and any interested parties from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of my massage therapist or the establishment where massage therapy services are received, whether a COVID-19 infection occurs before, during, or after participation in any massage therapy session. *

I agree

In the event I contract Covid-19, I will notify my therapist as soon as possible. *

I agree

E-MAIL POLICY - We will use your e-mail address for appointment reminders, promotions and news from Body Compass LLC. Your privacy is important to us. We will not sell, rent, or give your name or address to anyone. To unsubscribe, or to receive less or more information, you can call, or e-mail Body Compass LLC at anytime. *

I agree

I disagree

INAPPROPRIATE BEHAVIOR POLICY - I understand that massage therapy is for relaxation and therapeutic purposes only. There is absolutely no sexual component to massage whatsoever. Any insinuation, joke, gesture, conversation, or request otherwise will result in immediate termination of my session and a refusal of any and all services in the future. I understand that I will be charged the full service fee regardless of the length of my session. I understand that depending on the inappropriate behavior exhibited a report may be filed with the local authorities if necessary. I will treat the therapist with respect and dignity and in return I will be treated the same. *

I agree