Terms and Conditions *

Please take a moment to carefully read the following terms and conditions. By signing below, you are confirming that you agree to be bound by these terms and conditions. LEGAL INFORMATION Massage and/or body work may not be appropriate with certain medical conditions and a referral from your health care provider may be required prior to service being provided and in any event, if you have a medical condition, it is recommended that you consult with your health care provider prior to receiving massage and/or body work regarding the suitability of massage and/or body work. I understand that the massage and/or body work l receive (the “Session”) is provided for the basic purpose of relaxation and relief of muscular tension. I hereby give my consent to receive the Session and acknowledge that I am doing so at my own risk. I acknowledge that I have had the opportunity to ask questions about the Session. If l experience any pain or discomfort during the Session, l will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. If I have concerns or feel uncomfortable with the practitioner, I will immediately bring it to the attention of management. I further understand that the Session is not a replacement for medical care and should not be construed as a substitute for medical examination, diagnosis, advice or treatment and that I should see a physician or other qualified medical specialist for any mental or physical ailment that I am aware of or experiencing. l understand that massage and/or body work practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness or provide any advice or service that would be provided by another licensed professional, and that nothing said in the course of the Session given should be construed in any way as medical advice or the substitute for medical advice. Because massage and/or body work should not be performed under certain medical conditions, I affirm that l have stated all my known medical conditions, and answered all questions honestly and I have stated prior to receiving the Session any medical or mental condition that may prevent me from this service. Mudras may, at its sole discretion refuse or discontinue the Session should the practitioner determine that it is unsafe or that I have engaged in inappropriate conduct. I hereby release and agree to defend, indemnify and hold Yellow Blue Moon Inc. d/b/a Mudras, its landlord, CPM Enterprises LLC d/b/a Drive 495, and both of their respective directors, officers, employees, contractors, agents and representatives harmless from any and all claims, demands, suits, costs, judgments, actual or claimed, including attorney fees, arising from my participation in the Session except as may result from their respective gross negligence or willful misconduct. EMAIL POLICY We will use your email address for appointment reminders, promotions and news from Mudras. Your privacy is important to us. We will not sell, rent or give your name or address to anyone. 48-HOUR CANCELLATION POLICY Should I cancel or miss an appointment with less than 48 hours notice, I authorize Mudras to charge me for the full session fee.

Agree

Your Name: *

First Name

Last Name

Date of Birth: *

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Phone Number: *

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Your Address: *

Address 1

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City

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Where Did You Hear About Us?: *

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Are you pregnant or trying to become pregnant? *

Yes

No

Postpartum two years or less?: *

Yes

No

If yes, brith date:

(optional)

MM

DD

YYYY

Musculoskeletal - Please check all that applies:

(optional)

Bone or joint disease

Tendonitis/Bursitis

Arthritis/Gout

Jaw Pain (TMJ)

Spinal Problems

Osteoporosis

Carpal Tunnel

Whiplash

Scoliosis/Torticollis

Circulatory - Please check all that applies:

(optional)

Heart Condition

Phlebitis/Varicose Veins

High Blood Pressure

Low Blood Pressure

Thrombosis/Embolism

Varicose Veins

Respiratory - Please check all that applies:

(optional)

Breathing Difficulty/Asthma

Sinus Problems

Nervous System - Please check all that applies:

(optional)

Numbing/Tingling

Pinched Nerve

Paralysis

Sciatica

Skin - Please check all that applies:

(optional)

Athlete's Foot

Herpes/Cold Sores

Psychological - Please check all that applies:

(optional)

Anxiety/Stress

Depression

Other - Do you suffer from any of the following conditions?: *

(optional)

Cancer

Diabetes

Drug/Alcohol Use

Chronic Pain

Migraines/Headaches

Neck Pain/Back Pain

Seizures

Bruise Easily

Fibromyalgia

Immune System Disorder

Wear Contact Lenses / Dentures / Hearing Aids

None of the above

Signature *

Prior to your massage, please remove contact lenses and all jewelry. Pull long hair back with a clip or band. I have completed this form to the best of my ability and knowledge and agree to inform Mudras if any of the above information changes at any time.

First Name

Last Name