Questionnaire

    Part 1: Guest Liability Release

    Please note that all documents should be routed and approved through your legal counsel if you choose to use.

    RELEASE OF LIABILITY AND AGREEMENT NOT TO SUE, INDEMNIFICATION, HOLD HARMLESS, LIMITATION OF WARRANTY

    We all know that these are uncertain times. The risks of COVID-19 are not well understood and there is controversy among the experts on how the virus can spread and difficulty in scientifically determining whether anyone has the virus at any moment in time.

    In consideration for providing massage therapy services, by signing below you agree to accept all responsibility for the risk that you may contract COVID-19. While we are taking your safety and that of our staff very seriously, by employing new safety and sanitation initiatives, we cannot guarantee that any of these measures will completely protect you from contracting COVID-19.

    I agree that if I take any steps to make a claim for damages against PuraVida, its agents, employees or any other released parties arising out of my receipt of massage therapy services during my visit to PuraVida’s facilities, I shall be obligated to pay all attorneys’ fees and costs incurred as a result of such claim.

    I acknowledge that I can go elsewhere to receive massage therapy services, and I acknowledge that PuraVida is not the only spa where I can receive spa services. By signing this Agreement, I acknowledge that I am free to go to other salons and spas who may not require my agreement to accept responsibility for contracting COVID-19. I chose to have massage therapy services today at PuraVida.

    Part 2: Government 14 Day Health Questionnaire

    1. Have you had a COVID vaccination?

    2. Have you been in close contact the past 14 days with a person known to have COVID?

    3. Do you currently have fever or lower respiratory symptoms such as a cough or shortness of breath?

    Part 3: Basic Information

    Part 4: Medical Information

    Are you taking any medications?

    Are you currently pregnant?

    Do you suffer from chronic pain?

    Have you had any orthopedic injuries?

    Please indicate any of the following that apply to you.

    Part 5: Massage Information

    Have you had a professional massage before?

    What type of massage are you seeking?

    What pressure do you prefer?

    Do you have any allergies or sensitivities?

    Are there any areas (feet, face, abdomen, etc.) you do not want massaged?

    By signing below, you agree to the following. I have completed this 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.