I have completed this health form to the best of my knowledge.
I understand that massage therapy is a therapeutic health aid and is non-sexual.
I am aware of the benefits and risks of the services, assume any and all risks associated therewith
and voluntarily give my consent to receive the services from Krittiya Leoviriyakit, Licensed Massage
I understand that there is no implied or stated guarantee of success or effectiveness.
I acknowledge that the Licensed massage therapist does not diagnose illness, disease or any other
physical or mental disorder, nor do they prescribe medical treatment , pharmaceuticals or spinal
manipulation. I understand that Massage therapy cannot safely be performed when certain
medical conditions exist and that it is recommended that I see a primary health care provider for
I waive release, discharge and hold harmless Krittiya Leovirykait LMT from any and all liability for
any injuries, damages or claims relating to or resulting from my receipt of the services.
I acknowledge that I have read, and understand, the release and indemnification provisions set
forth the preceding paragraphs and agree to such terms.