Massage & Dowsing Release Form

Massage intake/release

Please read and digitally sign the below disclaimer BEFORE I begin my work with you.

I freely acknowledge that I am fully aware that Marcella Regal is not a medical doctor or any other kind of medical practitioner and she has not represented herself in any way as possessing any medical expertise or medical training whatsoever and she has not prescribed, diagnosed, treated or recommend any particular treatment, medication, or substance for me in respect of my injury, ailment, or disease that I may possess. I have not been cajoled, coerced, threatened, or persuaded by Marcella Regal to undergo or partake in any particular treatment, medication, or substance – and that I freely acknowledge that any unorthodox or unusual treatment or medication or substance that I may utilize is done with my full awareness and acknowledgement that it is of my own free will.

I, the undersigned, for myself, my heirs, hereby release and forever discharge Marcella Regal, from any and all actions, causes of action, claims and demands for or by reason of any damage, loss or injury, to person and property which heretofore has been or hereafter may be sustained in consequence of attending a workshop, or taking of any medication, substance, or treatment which I may use or consume in any respect of and for any attempts by myself or anyone on my behalf to cause temporary or permanent relief from the symptoms of any injury, ailment, or disease with which I have been or will be diagnosed.

I have read and understood that Marcella Regal’s fees are to be prepaid before my appointment is scheduled and that the fees are non-refundable. If I need to reschedule my appointment, I will not be entitled to a refund unless I have provided 24 hours notice. If I miss my appointment I will not be entitled to a refund. Fixx Your Health performs acupressure massage services for therapeutic purposes only. It is understood that any inappropriate behavior such as excessive drinking, drug use, illicit or sexually suggestive remarks, or advances made by the client will result in immediate termination of the session, and the client will be liable for payment for the “full” scheduled appointment. After the dispute is evaluated by Fixx Your Health, and we determine that the client was at fault, we have the right to process the client’s credit card.

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 signing this form, I acknowledge that I am aware of the risks involved and give consent to receive massage and bodywork from this practitioner.

First Name *

Email *

Last Name

Phone Number

Address, City and Zip

Emergency Contact Name

Physicians Name

Phone

Occupation

Returning Client

Activities (work and others)

Reason for massage

How often do you get a massage?

Have you ever had any injuries (broken bones, torn ligaments, surgeries)?

When?

Do you have any medical issues (pregnancy, diseases, skin disorders, infections, blood pressure, heart conditions, breathing, blood clots, arthritis, diabetes, cancer, etc.? Have you been infected with corona, Do you have any symptoms currently, Have you been exposed to another person with corona , Do you work in a high risk job, hospital, nursing home or other, have you been tested for corona, Please explain

Print Name for Digital Signature *

I keep all of our interactions completely confidential. I will listen carefully and pay specific attention to your desires for healing and will then dedicate my focus toward helping you resolve your issues. I love helping people meet their personal goals and expectations.

Date of Digital Signature *

Comment

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