Documents

First and Last Name*

Mailling Address*

Email Address*

Cell Phone*

Home Phone

Date of Birth*

Sex*

Who may we call in case of an emergency?*

Emergency Contact Phone Number*

Please list any medical concerns; anything you are seeing a physician for presently or within the last 2-3 years..*

Ex. high blood pressure, heart issues, contagious diseases, arthritis, fibromyalgia, cancer, recent injuries or surgeries, etc. PLEASE BE HONEST TO ENSURE NO FURTHER HARM IS CAUSED DO TO MASSAGE THERAPY! *If none; state "none".

Your Body: Please check all that apply

Covid History : Select all that apply*

*please understand that close contact with people increases the risk or infection from Covid-19. By consenting to massage, you acknowledge you are aware of this risk and will not hold Lightway Healing Therapeutic Massage, LLC or Stacy Viney liable if contracting Covid-19*

I have been tested for covid in the past 2 weeksI tested POSITIVE for covidI tested NEGATIVE for covidI have been caring for someone who is ill within the past 2 weeks.I currently have at least one of the following symptoms: fever, chills, cough, sore throat, diarrhea, shortness of breath, rash/skin lesion, or loss of taste/smell.Does NOT apply to me

Consent to Massage*

By providing your full name, you give Lightway Healing Therapeutic Massage, LLC (Stacy Viney, LMT) consent to massage. That you have provided truthful information to the best of your knowledge. That if you experience any pain or discomfort during your session, you will inform the massage therapist immediately. You understand that any and all illicit or sexually suggestive remarks or advances made by you will result in immediate termination of the session, and you will still be responsible for payment of the full session charged to the card you have on file. Lastly, if you haven't already, please read the Policies and Procedures. Your debit/credit card will be held on file and only used for small service charges for late cancellations and full service charges for same day cancellation and no shows. *

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Client History/Intake Form

Please complete or print out and bring to your appointment (link Below)