- Step 1 of 3 Please enter your personal informationFirst and Last Name *Date of Birth (DD-MM-YY)Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *Phone *Occupation *Emergency Contact PersonPhoneNextHealth informationAre you currently under a physicians care for an acute or chronic illness? *NoYesIf yes please explain: Are you currently taking any prescribed medication or dietary supplements? *NoYesIf yes please explain: Have you received a massage before? *NoYesHow did you hear about Vivire Wellness? *Word Of MouthGoogleFacebookInstagramYoutubeLinkedInEmail PromoPrintcheck all that applyWhat are your goals for this session?Please list areas of tension, stress and/or pain you wish to be addressed: *HeadNeckShouldersUpper BackMiddle BackLower BackGlutesQuads / HamstringsCalvesFeetOtherNextHealth information COntinued...Please check all current conditions *Abdominal /digestive problems AllergiesAnxietyArthritis/ tendinitis Asthma or lung conditionAthletes foot Blood clots Chronic pain Circulatory/ heart problemsConstipation/ DiarrheaDepressionDiabetes FatigueHeadaches, migraine Hearing problems HerniaHigh blood pressure Jaw pain/TMJ pain Low blood pressureMuscle/bone injuries Muscle/joint pain Numbness/tinglingPregnancy Rash/fungusSinus problemsSleep difficulties Spinal disorders Sprain/strain Tension/stressVision problemsVaricose veins OtherDo you Have any allergies? if yes please indicateElaborate on noted areas above: Please list any recent injuries or surgeries within the past 5 years: Please list your stress-reduction activities, hobbies, exercise and/or sport participation:DUE TO COVID-19 Please check any that apply, If the answer to any of the questions below is yes, you will not be able to schedule an appointment or you will be asked to reschedule your appointment. <br><br>Have you tested positive for or been diagnosed as having COVID-19 or any other communicable disease?Have you been around someone who has tested positive for or been diagnosed as having COVID-19 or any other communicable disease?Have you had a cough within the last 14 days? Have you had a fever (defined as above 99.6 degrees) within the last 14 days?Have you experienced shortness of breath or had trouble breathing within the last 14 days?-Have you had persistent pain, pressure, or tightness in the chest within the last 14 days?Have you been around anyone exhibiting any of these symptoms during the last 14 days?Are you living with anyone who is sick or in quarantine? If you are a healthcare provider please contact us directly to schedule your appointment.I have stated all 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 massage therapist if anything changes in my status I understand that my massage therapist does not diagnose illness or disease, nor perform any spinal manipulations, and does not prescribe any 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. If I am unable to attend my scheduled appointment. Sexual advances, request for sexual favors, and other verbal or physical conduct of a sexual nature will constitute sexual harassment and will not be tolerated. 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 in part, of the aforesaid massage therapy, I hereby hold harmless and indemnify the therapist, their principals, and agents from all claims and liability whatsoever. "I have stated all conditions that I am aware of and this information is true and accurate to the best of my knowledge. I will inform my healthcare provider and massage therapist if anything changes in my status. I understand that massage/bodywork I receive is for the purpose of stress reduction and the relief from muscular tension, spasm or pain and to increase circulation. If I experience any pain or discomfort, I will immediately inform my massage therapist so that the pressure and/or methods can can be adjusted to my comfort level. I understand that my massage therapist does not diagnose illness or disease, nor perform any spinal manipulations, and does not prescribe any medications/treatments. I acknowledge that massage is not a substitute for a medical examination or diagnosis and that I should see my healthcare provider for those services. If i am unable to attend my scheduled appointment. 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 by Villar Massage and Vivire Wellness, I hereby hold harmless and indemnify the therapist, their principals, and agents from all claims and liability whatsoever." The waiver below will need to be agreed to and signed for every appointment. The above may be refined or adjusted as needed. Rest assured that we are doing everything we can to ensure everyone’s safety and comfort as society as a whole strives to return to normalcy. As with the transmission of any communicable disease like a cold or the flu, you may be exposed To COVID-19, also known as “coronavirus”, at any time or in any place. Be assured that we have always followed state and federal regulations and recommended universal personal protection and disinfection protocols to clean the spa and to limit the transmission of diseases and we will continue to do so. Despite our careful attention to sterilization and disinfection there is still a chance that you could be exposed to an illness in the spa, just as you might be at your gym, grocery store, or favorite restaurant. Although we have taken measures to provide social distancing at the spa, due to the nature of the services we provide, it is not possible to maintain social distancing between the client and the staff and sometimes other clients at all times. By making your appointment, signing below, and receiving the services, you hereby agree to abide by the above rules and accept the risk and release Vivire Wellness and Villar Massage from any liability should you get sick. I acknowledge by signing below that 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. I agree to the Practice Policies and Client Informed Consent Vivire Wellness has but in place. *YesNameSubmit