Declaration of Health and Liability Release
Your Private Health Information (PHI) is important and information submitted via this form to Relief Therapy - Christopher Pierce ("Christopher", "Chris", "I", "me") is protected under HIPAA with a BAA via Google Services. What this means is that PHI submitted in this form is kept private according to regulations under HIPAA. For more specific information and questions contact or refer to
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By typing my full name below, I verify that on this date I do not have, to the best of my knowledge, any condition which could be spread during the normal course of massage or close contact, nor am I experiencing fever, chills, shortness of breath, or cough. I also release Christopher, and any companies he associates with, from liability associated with potential exposure to diseases or infections during my appointment. *
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