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Intake Form

Please fill out the following form before your first visit to PostureWorks.

Musculoskeletal Health
Nervous System Health
Circulatory Health
Digestive Health
Respiratory Health
Skin Health
Reproductive Health
If Pregnant are you experiencing any of the following medical conditions?
If Pregnant are you experiencing any of the symptoms listed below?
Have you been hospitalized in the last 12 months?

Client Agreement:

It is my choice to receive treatment.  I am aware of the benefits and risks of massage and exercise and give my consent for massage, stretching, yoga, or personal training.  I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments.  I acknowledge that massage therapy, stretching, yoga, or personal training is not a substitute for medical care, medical examination or diagnosis.  I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status. By signing this waiver, I hereby release Leah Klein, insurers,  and  indedpendent contractors working at PostureWorks, PLLC. from liability past, present, and future relating to bodywork, stretching, and massage therapy.

Pregnancy Massage Only:

 I understand there are possible contraindications to massage therapy during pregancy.  In addition, I have discussed this with my physician and have had the opportunity to ask questions of the massage therapist and of my physician about the information. 

I understand the information and confirm that: 

I have not experienced any of the complications listed above.

I have not experienced and of the conditions listed which would make it unwise to have massage therapy.

I am experiencing a low risk pregnancy.

I am receiving medical care including regular check-ups throught my pregnancy.

I understand that I will be receiving massage therapy as a form of adjunctive health care only and that this therapy is not inteded to replace appropriate medical care. 

I do forever release PostureWorks Clinical Massage and Stretch Therapy, it' massage therapists, insurers, and all independent contractors working at PostureWorks from all liabiliity of any nature whatsoever, whether past, present, or future for injury or damage which may occur to myself or my family as a result of my receiving massage therapy during this childbearing year.  

I agree to hold harmless and defend the practicioner of and from all actions, claims, or other legal or administative action that has arisen or may arise directly from me and my child.

Upload File

Driver License is required to keep on file for the safety of the therapists. 

Once photo is taken it will say image.jpg below the box even if you don't see the picture.  It has submitted if it says, " thanks for submitting" below the submit button once it is pressed.  

Thanks for submitting!

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