Name *

First Name

Last Name

Phone *

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Address

Address 1

Address 2

City

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Optional Additions (No Charge)

Aromatherapy

Cupping

CBD Oil

Please check any that apply

Headaches/migraines

Joint stiffness/swelling

Jaw pain

Bursitis

Scoliosis

Arthritis

Planta Fasciitis

Lymphedema

IBS

Dizziness/fainting

Varicose Veins

Blood Clots

Heart Condition

Low/High Blood Pressure

Pregnant

Endometriosis

Numbness/tingling

Restless Leg Syndrome

Siezures

Fibromyalgia

Cancer

Diabetes

Depression

Anxiety

Contagious Skin Condition

Drug Use

Cancellation Policy and Informed Consent to Receive Massage *

Cancellation Policy and Informed Consent to Receive Massage and Bodywork (Copy) It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. 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 is not a substitute for medical care, medical examination, or diagnosis. I have completed this form to the best of my ability and I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status. 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 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. By checking "I have read and agree to the terms above," I agree to waive all liabilities toward Aneka Otte and Chariot Massage and Bodywork for any injury or damages incurred due to any misrepresentation of my health history.

I have read and agree to the terms above.

If possible, please give 48 hours notice prior to cancelling or rescheduling your appointment by emailing chariotmassageaz@gmail.com

I understand and agree to the cancellation policy.