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Ace of Cups Massage Intake Form

  • MM slash DD slash YYYY
  • Health History (please check all that apply)

  • COVID-19 Health Information & Informed Consent

    This document contains important information about your decision to receive services in light of the COVID-19 public health crisis. Please read and fill out this form carefully and let me know if you have any questions.
  • MM slash DD slash YYYY
  • The following questions are specific to a new aspect of COVID-19 involving blood coagulation

  • Are you under the age of 17?  If yes, you must have the written consent of your parent or guardian to participate in our massage therapy services.

    The massage therapist will not perform a breast massage on female clients without the written consent of the client prior to the massage session.  Draping will be used during the massage session unless otherwise agreed to by both client and therapist. If the client is uncomfortable for any reason, the client may ask to end the massage session, and the session will be ended.

    Massage therapy is not a substitute for medical examination or diagnosis.  It is recommended that I see a physician for any physical ailment that I may have.  I understand that the massage therapist does not prescribe medical treatments or pharmaceuticals, and does not perform any spinal adjustments.  I am aware that if I have any serious medical diagnosis, I must provide a physician’s written consent prior to service.

     
  • Consent for Treatment

    To proceed with receiving care, I confirm and understand the following

    I understand that the novel Coronavirus (COVID-19) has been declared a global pandemic by the World Health Organization (WHO). I further understand that COVID-19 is extremely contagious and may be contracted from various sources. I understand COVID-19 has a long incubation period during which carriers of the virus may not show symptoms and still be contagious.

    I understand that I am the decision maker for my health care. To the best of their ability, my practitioner will provide me with information to assist me in making informed choices. This process is often referred to as “informed consent” and involves my understanding and agreement regarding recommended care, and the benefits and risks associated with the provision of health care during a pandemic. Given the current limitations of COVID-19 virus testing, I understand determining who is infected with COVID-19 is exceptionally difficult.

    I understand that preventative measures and intensified sanitation protocols intended to reduce the spread of COVID-19 have been implemented. However, because this work involves close physical proximity over an extended period of time in a closed space, there may be an elevated risk of disease transmission, including COVID-19. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this treatment and give my express permission to you and the staff at your offices to proceed with providing care.

    I have been offered a copy of this consent form.

    I KNOWINGLY AND WILLINGLY CONSENT TO THE TREATMENT WITH THE FULL UNDERSTANDING AND DISCLOSURE OF THE RISKS ASSOCIATED WITH RECEIVING CARE DURING THE COVID-19 PANDEMIC. I CONFIRM ALL OF MY QUESTIONS WERE ANSWERED TO MY SATISFACTION.

    I HAVE READ, OR HAVE HAD READ TO ME, THE ABOVE COVID-19 RISK INFORMED CONSENT TO TREAT. I APPRECIATE THAT IT IS NOT POSSIBLE TO CONSIDER EVERY POSSIBLE COMPLICATION TO CARE. I HAVE ALSO HAD AN OPPORTUNITY TO ASK QUESTIONS ABOUT ITS CONTENT, AND BY SIGNING BELOW, I AGREE WITH THE CURRENT OR FUTURE RECOMMENDATION TO RECEIVE CARE AS IS DEEMED APPROPRIATE FOR MY CIRCUMSTANCE. I INTEND THIS CONSENT TO COVER THE ENTIRE COURSE OF CARE FROM ALL PROVIDERS IN THIS OFFICE FOR MY PRESENT CONDITION AND FOR ANY FUTURE CONDITION(S) FOR WHICH I SEEK CARE FROM THIS OFFICE.

  • By signing this form, I consent to receive massage therapy as stated by the Texas Department of Licensing and Regulation. I understand that I can revoke consent for this and any future massage at any point without repercussions by any individual or governing entity.
  • MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.

What Folks are Saying About Ace of Cups Austin

"An oasis in the heart of downtown. Upon entering the space, you immediately feel relaxed and welcomed. The incredibly talented therapists and teachers have years of wisdom to share with our community. You won't be disappointed to spend any part of your day here!"

~ Robyn Stringfellow-Lein

"I had a pleasant experience with Ace Of Cups from start to finish! It was easy to get to and there was plenty of parking. The building was lovely inside and out. They also have crystals, candles, tarot cards, and some other neat things for sale at fair prices."

~ Amanda Hertsenberg

"Recommended. liked my first massage so much i booked again. chill vibe. i like that i can say "i want to be mindful of my body" and have someone help me through that. the first massage i booked the masseuse asked me to "breathe" into the knots she was trying to iron out."

~ J.P. Regalado

"My recent, second visit to Ace of Cups confirmed what I already knew from my first - Sam and her staff are expert, consummate professionals and extraordinary healers. From the first greeting at the entryway I was put at ease and made confident that I was in good hands."

~ Sean Collins

There is plenty of parking at Ace of Cups Massage and Wellness. There is a handicapped spot and ramp. Parking is behind the building in the alley between Cesar Chavez and Willow. Access the alley from Robert Martinez. Feel free to contact us with questions.

Get In Touch!

1-512.599.4800

2121 E Cesar Chavez St, Austin Tx 78702

email us here

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