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Therapist of the Month: Gonzalo Reategui
Therapist of the Month: Hannah Ross
Therapist of the Month: Jennifer Sahy
Massage of the Month
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,
is a downloadable/printable version of our intake form
Address Line 2
District of Columbia
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Phone (Cell or best contact number)
Phone (Secondary contact - not required)
Occupation / Employer
Primary Care Provider
Primary Care Provider Phone
Emergency Contact Phone
Massage History / Treatment Information
Have you ever received a professional massage?
Date of last massage
MM slash DD slash YYYY
What results do you want from your sessions?
Please check any areas of your body where you prefer not to receive massage:
Are you currently seeing a healthcare practitioner?
List stress Reduction and Exercise Activities. Please include frequency.
List current Medications, Herbals & Supplements and reason for use. Please Include OTCs such as Aspirin, Ibuprofen, Claritin, etc.
Surgeries (Include year and treatment received)
Accidents (Include year and treatment received)
1. Have you had a fever in the last 24 hours of 100°F or above?
2. Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath?
3. Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms?
Bone or Joint Disease
Tendinitis / Bursitis
Broken / Fractured Bones
Arthritis / Gout
Jaw Pain / TMD
Sprains / Strains
Low Back, Hip, Leg Pain
Neck, Shoulder, Arm Pain
Headaches, Head Injuries
Varicose Veins / Phlebitis
High / Low Blood Pressure
Thrombus / Embolism
Breathing Difficulty / Asthma
Herpes / Shingles
Numbness / Tingling
Ovarian / Menstrual Problems
If pregnant, Trimester:
Herpes / Cold Sores
Gas / Bloating
Irritable Bowel Syndrome
Cancer / Tumor
Bladder / Kidney Ailment
Drug / Alcohol Addiction
Caffeine / Tobacco Addiction
Migraines / Headaches
Anxiety / Stress Syndrome
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.
By checking this box I agree to the above statement.