Chair Massage Intake Form

Please fill out the form below prior to getting a chair massage treatment.*

Name

First Name

Last Name

Email Address

Reason for Massage

How Long Have You Had This Pain

Other Treatments In The Past Or Currently

Have you had any of these injuries in the past or currently being treated?

Concussion

Motor Vehicle Accident

Falls

Other / None of these things

Liability Waiver

I authorize M.O.A. Living Inc. and Contractors, to perform chair massage. I acknowledge that my choice to participate is my complete and personal responsibility. I have informed the practitioner of any medical or physical condition which may affect my ability to receive chair massage, including but not limited to, any heart conditions, lung conditions, high blood pressure, stroke or paralysis, diabetes, cancer, arthritis or joint problems, any back or neck problems, bruise easily or take blood thinners, numbness or tingling, headaches or migraines, infectious diseases, autoimmune diseases, recent surgeries,recent injuries, pregnancy. In consideration for this, I do hereby discharge this therapist, all affiliates, directors, officers and employees from any and all causes of action, suits, debts, claims and any kind whatsoever arising from or by reason of any injuries which might occur as a result of having a chair massage performed. By signing below, I acknowledge that I have read and understand the meaning of this waiver form.