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Medical Waiver

This document is to submit a request for a medical waiver for the In-Home Service charge. It is the goal of Metamorphosis Massage LLC to provide the best care in the safest way. However, certain medical conditions can make coming to Metamorphosis Massage LLC location to receive massage services a contraindication and/or cause undue hardship. Medical conditions that qualify will fall under the categories of autoimmune diseases, disabilities, limiting mobility diseases/dysfunctions, and recent trauma. This list is not all inclusive and Metamorphosis Massage LLC reserves the right to review these conditions on a case by case basis. Metamorphosis Massage LLC offers both permanent and temporary medical waiver depending on the qualifying condition. Metamorphosis Massage LLC will send an email with the decision and a note will be added to your client profile. 

First Name Last Name

_______________________ _________________________

Email

__________________________

Medical Condition

______________________________

Date of Diagnosis Duration (i.e. 6 weeks for broken limb)

________________ _________________

How does this affect your ability to come to the office?

______________________________________________________________________________________________________________________

I understand that Metamorphosis Massage LLC is HIPPA compliant and follows all applicable privacy laws as it pertains to this document. I agree to provide a Doctor’s note upon written request from Metamorphosis Massage LLC. I agree that Metamorphosis Massage LLC has the right to revoke this waiver at any time for any reason, and will be communicated in writing. This waiver does not waive the cost of the massage services provided, and I agree to pay in full for those services booked. 

I agree that the above information is true and accurate to the best of my knowledge. I agree that this waiver may be signed electronically, the effect of which will be the same as assigned if we sign this waiver by hand and the intention of which is that both parties desire to be bound by all the terms of this waiver.

________________________________

Signature

____________

Date

For office use only:

Approved 

Temporary: End Date ______________

Permanent 

______________________________

Signature 

____________

Date

Denied

______________________________________________________________________

Reason Denied

______________________________

Signature

____________

Date