Date of Birth
* Date of Birth
* Cell Phone
Who can we thank for this referral?
Did you experience any pain or bruising during or after your massage? If yes, please explain
Are you pregnant? If so how far along are you?
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.
I AGREE & UNDERSTAND
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.
YES I agree & understand.
Thank you! We are looking forward to meeting you. Please visit our FAQ page to answer any questions you have to be prepared for your appointment.