Initial Intake, Consent, and Waiver
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Email *
Full Name *
Date of Birth *
Contact Cell Number *
Emergency Contact Name *
Emergency Contact Cell Number *
Referred By *
How did you learn about me?
Previous Massage *
Have you had a professional massage before; if so, approximately how long ago?
Preferences *
What kind of pressure do you prefer-light, medium, or firm? Is there a part of your body you don't want to be massaged, that is sensitive to touch, bruises easily, or that I need to know anything about?
Current Medications
List current medications and the conditions you are currently treating with them.
Allergies
Tell me about any allergies or hypersensitivities to anything that could be in a lotion/oil.
Accidents/Surgeries *
List any major accidents or surgeries (include dates).
Reason for Initial Visit *
Include any symptoms you have, along with when you first started having them, whether they are constant or intermittent,  whether you've had any previous treatments for the condition, and what makes it better and worse.
Pregnant? *
FSM is not applied while pregnant. It has not been shown to create problems during pregnancy but risk is unknown due to FSM increasing endorphins and reducing prostaglandins.
Injury/Surgery Less Than 6 Weeks Old? *
The frequencies for removing scar tissue remove repair tissue helping heal new injuries so I would make sure not to use those if you have a new injury or had a recent surgery.
Infection or Encapsulated Infection? *
Passing current through an encapsulated infection (like a tooth abscess) can sometimes increase pain so we would avoid those areas. And if you have any type of other infection, I won't use frequencies that will quiet inflammation and immune system function because those are a necessary part of infection recovery.
Health History *
Mark any that apply.
Required
Health Elaboration
Provide elaboration for any of the above conditions and list any other medical conditions.
Cancellation Policy, Informed Consent, and Liability Waiver *

In the event of a cancellation with less than 24 hours' notice, or a missed appointment with no communication, you will be charged for the full amount of the service, and be asked to pay for all future sessions at the time of booking.

I have read What to Expect at My Massage which also explains the benefits and risks of massage and frequency specific microcurrent (FSM).

It is my choice to receive massage, bodywork, and/or FSM and I am aware of the benefits and risks and give my consent for sessions with Tracy Heilers. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. 

I affirm that I have notified my therapist of all known medical conditions and injuries. I understand that providing incorrect information can be dangerous to my health. I agree to inform my therapist of any changes in my health and medical conditions. I understand that there shall be no liability on the therapist's part should I forget to do so. There are certain medical conditions in which receiving massage, bodywork, and/or FSM may not be appropriate and referral from a physician may be required. 

I understand that massage, bodywork, and/or FSM are not a substitute for medical care. I understand that my therapist is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness, and that nothing said in the course of any session should be construed as such. The massage, bodywork, and/or FSM I receive is provided for the basic purpose of relaxation and relief of muscular tension.

If I experience any pain or discomfort during the session, I will immediately inform my therapist so that the pressure/strokes may be adjusted. I will not hold my therapist responsible for any pain or discomfort I experience during or after the session.

I understand that massage is entirely therapeutic and non-sexual in nature. Any illicit or sexually suggestive remarks or advances made by the client will result in the immediate termination of the session and the client will be liable for payment of scheduled appointment.

By typing my name below, I affirm I  understand the above statements and hereby waive and release my therapist from any and all liability, past, present, and future relating to massage therapy, bodywork, and/or FSM.
Minor
Only if applicable: By typing my name below, I hereby authorize Tracy Heilers to administer massage, bodywork, and/or FSM to my child or dependent.
A copy of your responses will be emailed to the address you provided.
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