Massage Intake Form Please enable JavaScript in your browser to complete this form.Name *FirstLastWho should we thank for this referral?Date of BirthMobile Phone *Email *Emergency Contact & Cell Phone *OccupationDo you have any of the following conditions: Pregnant, High Blood Pressure or Heart Condition(s)? *List all allergies *Are you allergic to grapeseed oil when used for massage? *YesNoHow many days per week do you exercise? *None1-2 days3-5 days6+ daysWhat medications do you take routinely? *How will you be paying for your massage service? *CashVENMOIf paying with VENMO, what is your account profile name?Terms of Service *I accept the terms of service belowAs a condition of and in consideration for receiving massage therapy services offered by Corporate Massage Kneads, LLC the undersigned hereby signs this Release and represents the following. 1. I hereby RELEASE, DISCHARGE, COVENANT NOT TO SUE, and HOLD HARMLESS Corporate Massage Kneads and its agents and officers, and all of its massage therapists (the “Releasees”) from all liability to the undersigned for any and all loss or damage, and any claim or cause of action, on account of injury to my person or property due to or resulting from the undersigned’s receipt of any massage therapy services being offered by the Releasees. 2. I acknowledge that my election to receive massage therapy is my personal decision and entirely voluntary. 3. I HEREBY ASSUME FULL RESPONSIBILITY FOR RISK OF BODILY INJURY RESULTING FROM MY RECEIVING MASSAGE THERAPY FROM EITHER JANET CONSTANTINO, LMT OR ANY MASSAGE THERAPIST CONTRACTED BY CORPORATE MASSAGE KNEADS TO PROVIDE THIS SERVICE. 4. I EXPRESSLY ACKNOWLEDGE that I am not currently suffering from any ailment that could adversely be affected by massage. Furthermore, if I experience any pain or discomfort during the massage, I will immediately notify the massage therapist so that the pressure methods can be adjusted to my comfort level. 5. This agreement is to be construed according to the laws of the State of North Carolina and, if any portion hereof is held invalid, it is agreed that the remainder continues to have full force and legal effect. BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ AND VOLUNTARILY SIGNED THIS RELEASE OF LIABILITY, AND I FURTHER AGREE THAT NO ORAL REPRESENTATIONS OR STATEMENTS OF INDUCEMENT APART FROM THIS WRITTEN AGREEMENT HAVE BEEN MADE TO ME. I HAVE READ THIS DOCUMENT, AND I UNDERSTAND IT IS A RELEASE OF ALL POTENTIAL CLAIMS. I UNDERSTAND THAT I ASSUME ALL RISKS INHERENT IN RECEIVING MASSAGE THERAPY. I understand that payment is due upon the completion of the table or chair massage either in cash or through VENMO. Submit
