NavaDeMassage NAVA DE MASSAGE CLIENT PRESCREEN AND WAIVER Nava de Massage is committed to your well-being, the well-being of our employees and our community. Due to the pandemic of the coronavirus illness, COVID-19, we have implemented additional standards in attempt to stop the spread of the virus and we follow or exceed sanitation/disinfection guidelines issued by the Center for Disease Control (CDC). I UNDERSTAND THAT THE CDC HAS PUBLISHED THE FOLLOWING AS SYMPTOMS OF COVID‐19: Fever*, cough, shortness of breath or difficulty breathing, chills, repeated shaking with chills, sore throat, new loss of taste or smell THE FOLLOWING STATEMENTS ARE TRUE FOR ME AND ALL MY HOUSEHOLD MEMBERS: We are not currently experiencing any of the above symptoms. We have not been diagnosed with COVID-19 in the past 30 days. We have not knowingly been exposed to anyone with COVID-19 within the past 30 days. We have not traveled outside of the country or to/from any COVID-19 ‘hot spots’ within the past 30 days. I ALSO ACKNOWLEDGE THE FOLLOWING: A person can unintentionally spread COVID-19 to others even if they do not feel sick or have symptoms. Masks are meant to reduce the possibility of spreading the virus when infection is known or unknown; they do not block the virus. I understand and acknowledge that my therapist, the staff, this business, or the franchisor of this business cannot completely control the spread of COVID-19 and I have chosen to enter this business and consent to receive close contact service(s) with full knowledge of the risk of contracting COVID-19 when social distancing is not observed. Because we are all in this together, your therapist and all employees of this Nava de Massage Location, also acknowledge and agree to these same standards and statements every day. By signing below, I agree not to hold my therapist, the staff, this business, or the franchisor of this business liable for any exposure to COVID-19 while at this location.Guest Name:Date Agreed:* Date Format: MM slash DD slash YYYY Please fill in date.COVID Waiver Agreement*YesNoNava de Massage 504 W. Gray Suit A Houston Tx 77019 Tel.713-497-5882INFORMED CONSENT TO MASSAGE THERAPY TREATMENTI understand that the massage therapist is providing massage therapy services within their scope of practice as defined by Nava de Massage. I hereby consent for my therapist to treat me with massage therapy for the above noted purposes including such assessments, examinations and techniques, which may be recommended, by my therapist. I acknowledge that the therapist is not a physician and does not diagnose illness or disease or any other physical or mental disorder. I clearly understand that massage therapy is not a substitute for a medical examination. It is recommended that I attend my personal physician for any ailments that I may be experiencing. I acknowledge that no assurance or guarantee has been provided to me as to the results of the treatment. I acknowledge that with any treatment there can be risks and those risks have been explained to me and I assume those risks. I acknowledge and understand that the therapist must be fully aware of my existing medical conditions. I have completed my medical history form as provided by my therapist and disclosed to the therapist all of those medical conditions affecting me. It is my responsibility to keep the massage therapist updated on my medical history. The information I have provided is true and complete to the best of my knowledge. I have read the above noted consent and I have had the opportunity to question the contents and my therapy. By signing this form, I confirm my consent to treatment and intend this consent to cover the treatment discussed with me and such additional treatment as proposed by my therapist from time to time, to deal with my physical condition and for which I have sought treatment. I understand that at any time I may withdraw my consent and treatment will be stopped. Privacy will be assured as I have the right to undress only to my comfort level and according to requirements of the treatment. Draping will be used by the therapist as required to expose only those parts of my body that require treatment and/or as I choose to ensure my comfort during treatment. Cancellation of any appointment must be received at least 24 hours in advance; otherwise 50% of the appointment fee is due. The therapist may refuse to treat any client or their body with just and reasonable cause.Informed Consent* I agree to the policy.Patient InformationName*Phone (Day)*Phone (Night)AddressCity/State/ZipDOBOccupationEmployerPrimary PhysicianHow did you hear about us?Medical InformationMassage InformationAre you currently pregnant?*YesNoHow far along?Any high risk factors?What type of massage are you seeking? Relaxation Thai Combo Therapeutic / Deep Tissue Other Other (Type of massage)Do you suffer from chronic pain?*YesNoPlease explain chronic painWhat makes it better?What makes it worse?What pressure do you prefer?LightMediumDeepDo you have any allergies or sensitivities?*YesNoPlease explain sensitivitiesHave you had any orthopedic injuries?*YesNoPlease list injuriesPlease indicate any of the following that apply to you. Cancer Headaches / Migraines Arthritis Diabetes Joint Replacement High / Low Blood Pressure Neuropathy Fibromyalgia Stroke Heart Attack Kidney Dysfunction Blood Clots Numbness Sprains or Strains Explain any conditions you have marked aboveAre there any areas (feet, face, abdomen, etc. ) you do not want massaged?*YesNoPlease explain (do not massage)What are your goals for this treatment session?Please describe any areas of discomfortClient Name*Therapist NameSigned Date* Date Format: MM slash DD slash YYYY Therapist Signed DateI Agree* [I agree.]By checking the box [I Agree], you are agreeing to the following: I have completed the form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time.