Client In-Take

Name

Have you tested positive for covid-19 in the past ten days, or currently awaiting test results? Are you experiencing any flu-like symptoms including fever greater than 100.3, body aches, sore throat, cough or difficulty breathing?

Yes

Date

Initials

By electronically initialing above I confirm that the information given in this form is true. I acknowledge that massage therapy is entirely theraputic and non-sexual in nature and any inappropriate or suggestive remarks or actions will result in immediate termination of the session without refund, and will be prosecuted to the maximum extent of the law. I acknowledge and assume my potential risk of exposure to viruses and bacteria including covid-19 by receiving massage therapy, and I hereby waive and release my therapist and Mother Nurture LLC from any and all liability, past, present, and future relating to the provision of professional massage therapy.

Thanks for submitting!

847-732-5009

Mother Nurture

Harbor Country's Premier In-Home Massage Therapy

Client In-Take