Family First Chiropractic
800 HWY 290 West Bldg F
Dripping Springs, TX 78620
(512) 858-9355
ask@ffchiro.com
First Name:
Last Name:
DOB:
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Telephone (Home):
Telephone (Cell):
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Please read the following before signing
  • • I have stated all health conditions that I am aware of and this information is true and accurate to the best of my knowledge. I will inform my health care provider and the massage therapist if anything changes in my health status.

  • • I understand that the bodywork I receive is for the purposes of stress reduction, increased circulation and relief from muscular tension, spasm or pain. I understand that massage therapists do not diagnose illness or disease, perform spinal manipulations or prescribe medications/treatments. I acknowledge that massage is not a substitute for a medical examination or diagnosis and that I should see my health care provider for those services.

  • • I understand the massage therapist may use one or more of the following therapeutic techniques to best address my somatic imbalances: Swedish, Deep Tissue, Myofascial Release, Trigger Point Therapy, Medical Massage, Sports Massage, Thai Massage, Therapeutic Cupping Therapy, Acupressure, Reiki, Psychic Tension Release, Lomi Lomi, Prenatal, the Raindrop Technique, and Facial Movement Taping.

  • • I agree to inform my massage therapist if I experience any pain or discomfort so that my treatment can be adjusted to my comfort level. I also understand that if I am uncomfortable for any reason, I may request to end the massage session, and the massage therapist will then cease the massage.

  • • Proper draping procedures shall be used at all times. I understand that I should direct any concerns or questions about draping to my massage therapist.

  • • The therapist shall not engage in breast massage of a female client without prior written consent of the client.

  • • Sexual advances, requests for sexual favors and other verbal or physical conduct of a sexual nature will constitute as sexual harassment and will NOT be tolerated by either party.

  • In the event I need to cancel or reschedule my massage appointment, I agree to notify Family First Chiropractic at least 24 hours in advance of my scheduled massage appointment or to pay a fee in the amount of 50% of the cost of my missed session in accordance with the Family First Chiropractic cancellation policy. I understand that this fee applies to any missed appointment without 24 hours advance notice.

  • • I understand that I am receiving massage therapy at my own risk. In the event that I become injured either directly or indirectly as a result, in whole or part, of the aforesaid massage therapy I hereby hold harmless and indemnify the therapist, their principles and agents from all claims and liability whatsoever.
Client Signature:
Today's Date: 25 Apr 2019
Therapist Signature: