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Madison

6502 Grand Teton Plaza, Suite 101
Madison, WI 53719
608-770-2081

ppmmassagewi@gmail.com

“We refer a lot of our clients to Peak Performance Massage because it’s not just going to help them relax, it’s going to help them get better. It’s really helps heal their injuries and their movement patterns.” — Kane Sivesind

Copyright © 2021 Peak Performance Massage

MADISON

6502 Grand Teton Plaza

Suite 101

Madison, WI 53719

608-770-2081

  • Therapists
  • Services
  • Testimonials
  • Videos
  • Blog
  • Intake Form

COVID-19 / Treatment Consent Update

We have updated our intake form. All current and new clients must complete this form prior to receiving any services.

If you prefer, HERE is a downloadable/printable version of our intake form.

1Personal Info
2Massage History
3Health History

  • Personal Info

  • Massage History / Treatment Information

  • MM slash DD slash YYYY

  • Previous History

  • COVID-19 Information

  • Health History

  • Consent and Contract for Care

    It is my choice to receive massage therapy or yoga, and I give my consent to receive treatment. I have completed this form to the best of my knowledge and will inform the massage therapist or yoga instructor or any changes in my physical health.  I understand that massage therapist and yoga instructors can not diagnose illness, disease, or any other medical, mental, or emotional disorder. Nor do they prescribe medical treatment, pharmaceuticals, or perform spinal thrust manipulations. I realize that the treatment is being given for the well being of my body, mind and spirit. This includes stress reduction, relief from muscular tension, spasm or pain, also for increasing circulation or energy flow. I agree to communicate with my practitioner any time I feel like my wellbeing is compromised. I acknowledge that massage and yoga are not substitutes for medical examinations or diagnosis; I am responsible for consulting a qualified physician for any physical ailments that I have.  I understand that massage therapy and yoga is a therapeutic health aide and is non-sexual. 
    I understand that, because massage therapy work involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. By agreeing to this statement, I acknowledge that I am aware of the risks involved from receiving treatment at this time, I voluntarily agree to assume those risks, and I release and hold harmless the practitioner/business from any claims related thereto. I give my consent to receive treatment from this practitioner.