Name *

First Name

Last Name

Phone

(###)

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Emergency Contact

First Name

Last Name

Phone

(###)

###

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Please mark any of the following conditions you may have.

The following are known advisements and contraindications to providing massage services and will require you to use discretion for your own well-being. Severe medical conditions or pregnancy will require a note of authorization from your doctor prior to receiving massage service(s).

Cold/Flu/Virus

Fever within 24 hrs

Infection

Contagious Diseases

Allergies

Pregnant/Nursing

Pressure Touch Sensitive

Skin Sensitivity - Ticklish

Scent Sensitive

Recent Surgery

Open Wounds

Bruises/Abrasions

Acute/Chronic Pain

Please read the following: *

I understand that, although rare, side effects may result from a massage treatment. These could include but are not limited to, skin irritation from lotion/oils, pain or discomfort from prolonged positions, headache, bruising, swelling, numbness, nausea, and the temporary aggravation of pre-existing conditions. I understand that essential oils relaxation massage application is for the purpose of stress reduction, relief from muscular tension or spasm, or for increasing circulation. I understand the massage technician does not diagnose illness, disease or any other physical or mental disorder. The massage technician does not prescribe medical treatments nor perform spinal manipulations. I will inform the technician of my current condition at the time of each visit. I understand that essential oils application is for the purpose of stress reduction, relief from muscular tension or spasm, or for increasing circulation. I understand that the technician does not diagnose illness, disease or any other physical or mental disorder. The technician does not prescribe medical treatments nor perfom spinal manipulations. I will inform the technician of my current condition at the time of each visit. I consent to AromaTouch Wellness Experience and confirm that I am at least 18 years of age and have no conflicts to massage as described in the advisements and contraindications. I release Essentials of the Earth and it’s technicians from all liability associated with receiving massage service(s) and I take full responsibility for my own health and well-being.

Yes, I understand, acknowledge & consent to the all the details stated above.