Health Questionnaire for Massage Therapy

Aside from the benefits of massage, any treatment may affect a pre-existing condition, and some conditions may be contraindicated for certain types of body work. Therefore, this form must be completed prior to receiving massage. All information will be kept confidential.

Feel free to leave any fields that don’t apply to you blank.

Ngā mihi for your mahi!

Contact Information

Massage Information

Massage Therapy Waiver and Release Form

This waiver informs you of potential risks and your responsibilities. By ticking the Consent box below, you agree to the terms outlined.

Potential Risks

Massage therapy may involve risks, including:

Muscle soreness, bruising, or discomfort

Dizziness, light-headedness, or nausea

Allergic reactions to products used

Aggravation of existing or unknown conditions

The provider will take precautions to reduce risks. It is your responsibility to disclose any medical conditions, medications, or allergies that may affect treatment.

I understand and accept the risks involved with massage therapy, including those that cannot be entirely eliminated.

Scope of Practice and Limitations

I understand that massage therapy is not a substitute for medical treatment, diagnosis, or examination by a qualified health professional. The provider is not a medical doctor, and I am responsible for seeking medical advice for any health concerns outside the scope of massage therapy.

Health Disclosure

I confirm that I have provided accurate and complete health information and will notify the provider of any changes.

Limitation of Liability, Release and Indemnity

To the extent permitted by New Zealand law, I release and hold harmless Of Body and Earth, its employees, and agents from any claims related to the massage services, except in cases of gross negligence or willful misconduct.

I agree to indemnify Of Body and Earth against claims or losses arising from my participation in massage therapy, except where caused by the provider's gross negligence.

Respectful Conduct Policy

I acknowledge that the massage therapist has the right to maintain a safe and respectful environment. Any inappropriate behavior or sexual advances, whether verbal or physical, will result in the immediate termination of the session. In such cases, I agree to pay the full amount for the scheduled massage.