PLEASE LIST ANY INJURIES, SURGERIES, OR BROKEN BONES WITH DATES:

PLEASE CIRCLE ANY OF THE FOLLOWING CONDITIONS YOU ARE EXPERIENCING:

I understand if I experience any pain or discomfort during my session(s), I will immediately inform the therapist so the pressure and/or strokes can be adjusted to my level of comfort. I further understand massage/bodywork should not be construed as a substitute for medical examination, diagnosis or treatment and I should see a physician, chiropractor, or other qualified medical specialist for any medical for any mental or physical ailment I am aware of. I understand that massage therapist are not qualified to perform spinal or skeletal adjustment, diagnose, prescribe, nor treat any physical or mental illness, and nothing said in the course of the session should be construed as such. Because massage/bodywork should not be done 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 therapist updated as to any changes in my medical profile, and I understand there shall be no liability on the therapists’ part should I forget to do so. It is further understood 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 for the “Full” scheduled appointment. My signature below indicates that I hereby release Main Street Spa & Wellness Center and their staff from any liability for claims arising from the use of services. We reserve the right to restrict or refuse any client.