We do NOT ask you to wear a mask or vaccinate - your health is your responsibility
We encourage you to do your own research above and beyond your doctor's advice and/or pharmaceutical companies. We live in a crazy world and a crazy time; it seems people cannot be trusted. There is information on blood clotting, viruses, communicable diseases and illnesses coming out and it's quite disturbing.
The "Trials" for the vaccines were not complete until April 2023
Until then, it was "experimental" stage. The FDA only "cleared but not approved" usage due to the
"State of Emergency"...... the FDA now states the vaccines are and can be harmful.
Knowledge over Fear
If you have had ANY vaccine
We require you to wait 10+ days to make sure you are not having reactions or illness
The "Trials" for the vaccines were not complete until April 2023
Until then, it was "experimental" stage. The FDA only "cleared but not approved" usage due to the
"State of Emergency"...... the FDA now states the vaccines are and can be harmful.
Knowledge over Fear
If you have had ANY vaccine
We require you to wait 10+ days to make sure you are not having reactions or illness
Our Intake Form:
- I understand that massage therapy is provided for stress reduction, relaxation, relief from muscular tension, and improvement of circulation and energy flow.
- If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/strokes can be adjusted to my level of comfort. I will not hold my therapist responsible for any pain or discomfort I experience during or after the session.
- I understand that the services offered today are not a substitute for medical care. I understand that my therapist is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness.
- I affirm that I have notified my therapist of all known medical conditions and injuries (aka contraindications). (i.e. sprains, surgeries, sunburns, medications, open sores)
- I will notify the therapist of any previous Car Accidents, Whip Lash, Surgery, Broke Bones, etc.
- I agree to inform the therapist of any changes in my health and medical condition before the session. I understand that there shall be no liability on the therapist’s part should I forget to do so. *PLEASE update your INTAKE FORM every time you book, be sure to change the DATE.
- I understand that massage is entirely therapeutic and non-sexual in nature.
- 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.
- I will notify the therapist of any Allergies to the things the Therapist will use (i.e. lotion, aroma, latex, fibers, smells, candles, etc.)
- By signing this release, I hereby waive and release my therapist from any and all liability, past, present, and future relating to massage therapy and bodywork as well as all correlating services including laser therapy, PEMF and other equipment.
- We DO NOT wear masks and you are NOT require to. You are responsible for your own health. If YOU want to wear a mask that is okay. If YOU are uncomfortable with us NOT wearing one, then you need to cancel your appt immediately and request a refund. Any delay in this will result in a cancellation fee. (see cancellations)
- What you share with us can be used in your S.O.A.P. notes. We do not freely give out your information. We are H.I.P.A.A. and O.S.H.A. compliant.
- If you have had a injection, shot, vaccine - you must wait 10+ days before getting a massage. Earth Elements Massage is not responsible for any illness or *injury from you getting services at our location. You are ultimately responsible for YOUR health.
- If you cancel in LESS than 24 hours of your appt, we retain the right to charge you a fee of 100% for missed appointment. That includes pregnancy, illness/sickness, mask, personal preference or any other reason. Substitution must be approved ahead of your appointment.
- Our Therapist are sensitive and/or allergic to cigarette smoke and peppermint. Please refrain from using these on your appointment day.
- The word "CBD" will now be known as Hemp or C-B-D or Cee.Bee.Dee (or other variations). because to many "key-words" are being "censored" that emails AND texts are not going through.
- Emergency Contact information is Mandatory - Please go back 1 page and add it; this is for YOUR safety.
- Parking: If you cannot walk more than a few feet please text/call ahead so we can make sure we block off a space for you. Also, if you are in a wheelchair or LATE TERM Pregnancy, let us know so we can get you in safely.
If you have any questions or concerns about this form or our Policies & Procedures, please contact our office at 678.371.8938