Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date of Birth
*
MM
DD
YYYY
Cell Phone
*
(###)
###
####
Home Phone
(###)
###
####
Email
*
Occupation
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Who can we thank for this referral?
Have you ever experienced a professional massage/body work before?
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If yes to previous question, how recently
Did you experience any pain or bruising during or after your massage? If yes, please explain. If No, type N/A, etc.
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Have you had or do you have any of the following? Check all that apply.
*
Are you pregnant? If so how far along are you? If No, type N/A, etc.
*
Any accidents, injuries, or surgeries in the past 2 years? If yes, please describe. If No, type N/A, etc.
*
Any medical conditions, chronic or acute, that your therapist should be aware of? If No, type N/A, etc.
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I AGREE & UNDERSTAND
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The massage/ bodywork I receive is to provide relaxation and relief of muscular tension. I will let my massage therapist know if the pressure given needs to be adjusted to my comfort level. The massage/ bodywork should NOT be a substitute for a medical exam, diagnosis or treatment. I understand that the massage therapist is not qualified to perform spinal adjustment, diagnosis, prescribe or treat any physical or mental illness. I agree to keep the massage therapist updated with any medical changes and understand that there is no liability on the practitioners part should I forget to do so. By submitting this form I agree and understand all the statements made here in and that all the information submitted is accurate. Any discrepancies may cause the therapist to cancel my appointment.
