Welcome back! You can log in here. [clean-login] Or you can register here! Name(Required) First Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone(Required)Email(Required) Enter Email Confirm Email Username(Required)Password(Required) Enter Password Confirm Password Strength indicator Please check below all that apply:(Required) Spinal Problems Allergies High Blood Pressure Bruises Easily Varicose Veins Migraines Heart Conditions Injuries Smoke Currently Pregnant? Due Date:(Required)Please explain any checked above:Any medical conditions your therapist should be made aware of?(Required)One condition per line.Current Medications(Required)One medication per line.Type of massage you are requesting (please choose one)(Required) Swedish/Relaxation Deep Tissue Trigger Point Pregnancy Hot Stone Areas of pain/tension:(Required)If nothing, just input N/A.Areas to be avoided:(Required)If nothing, just input N/A.Massage therapy is not a substitute for medical examination or diagnosis. It is recommended that I see a physician for any physical ailment that I may have. I understand that the massage therapist does not prescribe medical treatments or pharmaceuticals and does not perform any spinal adjustments. I am aware that if I have any serious medical diagnosis, I must provide a physician’s written consent prior to services. The licensee shall drape the breasts of all female clients and not engage in breast massage of female clients unless the client gives written consent before each session involving breast massage. Draping of the genital area and gluteal cleavage will be used at all times during the session for all clients. The licensee must immediately end the massage session if a client initiates any verbal or physical contact that is sexual in nature. If the client is uncomfortable for any reason, the client may ask the licensee to end the massage, and the licensee will end the session. The licensee also has a right to end the session if uncomfortable for any reason.Consent(Required)Treatment Consent and Release of Liability for Unconditional Wellness and Athletic Therapy (UWAT) By signing below, you agree to the following: 1) I give my permission to receive massage therapy. 2) I understand that therapeutic massage is not a substitute for traditional medical treatment or medications. 3) I understand that the massage therapist does not diagnose illnesses or injuries, or prescribe medications. 4) I have clearance from my physician/health care provider to receive massage therapy. 5) I understand the risks associated and precautions with massage therapy include, but are not limited to: - Superficial bruising - Short-term muscle soreness, which may be helped by staying hydrated - Exacerbation of undiscovered injury - Cupping may lead to discoloration that may last for 1-3 weeks, and that hot tubs and prolonged hot showers must be avoided for at least 24 hours - Gua Sha may lead to discoloration and irritated skin. Hot showers or shaving may exacerbate the irritation In exchange for receiving services from Texas Athletic Therapy LLC, I, for myself and on behalf of my heirs, executors, administrators, and personal representatives hereby waive, release, discharge, and hold harmless texas Athletic Therapy, LLC, it’s members, offices, employees, and agents from any and all liability for any and all injuries, including death, damages, or claims relating to or resulting from my receipt of services now, or in the future, foreseen or unforeseen. Further, I will indemnify and hold texas Athletic Therapy LLC, it’s members, offices, agents, and employees harmless from and against any and all claims, rights, damages, liabilities, losses, cost, and expenses (including reasonable attorneys’ fees) arising from, or in connection with any injuries to other persons or damage to property caused by or attributed to me. 6) I understand the importance of informing my massage therapist of all medical conditions and medications I am taking, and to let the massage therapist know about any changes to these. I understand that there may be additional risks based on my physical condition. 7) I understand that it is my responsibility to inform my massage therapist of any discomfort I may feel during the massage session so he/she may adjust accordingly. 8) I understand that I or the massage therapist may terminate the session at any time for any reason. 9) I have been given a chance to ask questions about the massage therapy session and my questions have been answered. I acknowledge that I have read, and understand the release and indemnification provisions set forth in this document and have agreed to such terms. I agree to the above terms Are you under the age of 17? If yes, you must have the written consent of your parent or guardian to receive massage therapy services. Client Signature(Required)(Parent or Guardian if under the age of 17)Date(Required) MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged. Δ
