Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

May I add you to my mailing list?

Yes

No

Emergency Contact *

First Name

Last Name

Phone *

(###)

###

####

Is this a gift certificate?

Yes

No

Have you had massage or bodywork before?

Yes, a lot

Yes, some (5 or less sessions)

No

Are you pregnant?

If you think you may be pregnant or you ever become pregnant, please advise Olandra before your next appointment. Massage and bodywork may increase chances of miscarriage during the first trimester.

Yes

No

I'm not sure

Are you allergic to cats?

There are cats on the property and they sometimes enter the treatment room. If you're allergic, I'll take extra precautions, but I can't guarantee a total absence of dander.

Yes

No

Do any of the following conditions relate to you? If so, please describe

*No need to mark categories already mentioned in above sections

Allergies

Arthritis

Asthma or Shortness of Breath

Back problems/Pain

Blood Clots

Broken Bones in the past

Bruise Easily

Bursitis

Cancer/ Tumors

Cardiac Problems

Circulatory Problems

Constipation

Contact Lenses

Contagious Diseases

Degenerative Spine/Disk

Dentures

Diabetes

Digestive Problems (Crohnes, IBS, etc.)

Dizziness/Ringing in the ears

Ear aches or pains

Edema

Emotion/Mood

Endocrine/thyroid conditions

Epilepsy

Fungal Infections

Gas/Bloating

Infections

Are you wearing a hairpiece?

Headaches/Migraines

Hearing Problems

Heart/Circulatory Issues

Heart Attack

High Blood Pressure

Low Blood Pressure

Injury/Accidents

Joint Pain, Swelling, Stiffness

Kidney disease, infection

Muscular Issues

Memory Loss, confusion, easily overwhelmed

Neurological (e.g. MS, Parkinson’s, chronic pain)

Numbness or Tingling?

Neck Pain

Osteoporosis

Scoliosis

Seizures

Sinus Issues or pain

Sprains/Strains/Bruises

Stroke

Tendonitis

Varicose Veins

Vision Problems

Worts

Covid-19 Information *

Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, fever or shortness of breath?

Yes

No

*

Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms?

Yes

No

*

I agree to alert Olandra as soon as possible if either answer to the above questions changes before this appointment or any future appointment.

Yes, I agree

Consent for Treatment *

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, including COVID-19. By signing this form, I acknowledge that I am aware of the risks involved from receiving treatment at this time, I voluntarily agree to assume those risks, and I release and hold harmless the practitioner/business from any claims related thereto. I give my consent to receive treatment from this practitioner on this date and on any date thereafter. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage/bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. Understanding all of this, I give my consent to receive care.

I agree