Amanda Wongsonegoro, CMT
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Hendrickson Method
Therapeutic Massage
Deep Tissue Massage
Pregnancy Massage
Warm Stone Massage
Services
Services Link
Hendrickson Method
Therapeutic Massage
Deep Tissue Massage
Pregnancy Massage
Warm Stone Massage
Locations
About
Videos
Blog
Contact
Amanda Wongsonegoro, CMT
Booking
Intake Forms
Covid-19 Release Form
Due to the situation with the novel Coronavirus I am taking extra precautions with the intake of each client, health history review, as well as sanitation and disinfecting practices. Please read the following and sign below. Symptoms of COVID-19 include: - Fever - Fatigue - Dry cough - Difficulty breathing.
• I understand the above symptoms and affirm that I, as well as all household members, do not currently have, nor have experienced the symptoms listed above within the last 14 days.
• I affirm that I, as well as all household members, have not been diagnosed with COVID19 within the last 30 days.
• I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 within the last 30 days.
• I affirm that I, as well as all household members, have not traveled outside of the country, or to any city outside of our own that is or has been considered a “hot spot” for COVID-19 infections within the last 30 days.
• I understand that this business and my massage therapist cannot be held liable for any exposure to the virus or any other contagion caused by misinformation on this form or the health history provided by each client.
Please initial to accept and agree the above.
*
I, as your massage therapist, will abide and respect the same standards. I have improved and expanded my sanitation protocols to fight the spread of COVID-19 and other communicable conditions.
Thank you!
Client Health History Form
Name
*
First Name
Last Name
Date of Visit
Street Address
Phone
(###)
###
####
Date of Birth
Email
Occupation
1. Do you receive chiropractic care? Please list the reason:
2. How does your energy feel today? Are you mentally or emotionally drained? Sore from physical exertion?
3. Please select the conditions that apply to you:
Cancer (Doctor’s Note req.)
Arthritis
Pregnant
Bursitis
Heart Condition
Diabetes
Edema
TMJ
Eczema
High blood pressure (taking medication)
PMS
Bulging disks
Thyroid High/Low
Monthly cycle
4. Are you allergic to any oils or lotions?
Yes
No
5. Do you like your abdomen massaged?
Yes
No
6. Do you exercise regularly? How many times a week? What do you do?
7. What is your goal for this session today?
Please initial to accept and agree to receive massage from Amanda Wongsonegoro. I have the right to stop the session for whatever reason. I will communicate to the massage therapist if the pressure is too little or not enough.
*
TERMS
• I understand that all information that passes between us will remain confidential. • I understand that the massage therapist does not diagnose illness, disease, or any physical or mental disorder; does not prescribe medical treatment or pharmaceutical, and does not do any spinal manipulations. It is clear to me that this massage is not a substitute for medical examinations and/or diagnosis and that it is recommended that I see a physician for any physical ailment. • I have stated all my known medical conditions and take it upon myself to update it during subsequent visits. • I will comment on the comfort or discomfort of the massage at all times. I will ask for less or more pressure depending on my comfort level during the session. • I will not exercise after the session on the day it is given. I will drink more water than if I had not received a massage. • I will notify the therapist at least 24 hours in advance if I need to cancel my appointment. If I do not notify her I will still pay for the session. • The therapist will call me if I am running more than 10 minutes late for a session. • 30 minute sessions will be paid in full with no service. If it is a 60 minute, the balance of the time will be honored. If it is a 90 minute, the time left will be utilized for a massage session. All sessions will be paid for in full. • If I am under the age of 18 my parent(s) give consent to receive therapeutic massage. A signature from either parent must be on this form. • I release the massage therapist from all liability as I am responsible for communicating my medical conditions, medications, and comfort level.
Please initial to agree and accept terms.
Thank you!