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Health Declaration

Please fill out the following health declaration form in order to receive your massage. If not completed, massage therapist may refuse service due to health and safety. Please be considerate.

First Name

Last Name

Email

*I am NOT currently sick or having Covid related illness (if you're sick please reconsider)

I have a special request for massage lotion, oil, no lotion or oil product use, bed heated

No

Yes

Date

Initials

I confirm that the information given in this form is true

I agree to all the terms & conditions of My Healing Hands Massage

Thanks for submitting!

Please arrive 10 min before your schedule session for completion of your intake form (required)

© 2022 Starr Fit Club & Empowerment Coaching

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