MASSAGE THERAPY
MEDICAL INFORMATION FORM |
| NAME: DATE OF BIRTH: |
| ADDRESS: |
| CITY/STATE/ZIP: |
| TELEPHONE: |
| EMAIL: |
| OCCUPATION: REFERRED BY: |
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ANY CURRENT INJURIES? (CIRCLE ONE) YES NO
IF YES PLEASE EXPLAIN: |
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ANY AREAS OF PAIN OR SPASM THAT NEED EXTRA THERAPEUTIC ATTENTION TODAY?
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ARE YOU TAKING ANY MEDICATION? YES NO
(CIRCLE ONE)
IF YES, PLEASE LIST: |
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ARE YOU PREGNANT OR NURSING?(CIRCLE ONE) YES NO |
Please read below and sign in agreement to the following:
I understand the massage services being provided are designed to be a health aid and are in no way to take the place of a doctor’s care when it is indicated. Information exchanged during any massage session is educational in nature and is intended to help me become more familiar and conscious of my own health status. This session may be terminated at any time by either party due to unprofessional or inappropriate behavior. |
Exemption of liability:
It is agreed between the client and the practitioner that the practitioner shall not be held liable in contract or in tort for any personal injury of any nature whatsoever, that arises from or is the result of or contributed to by the treatment/session, or by failure to continue supplying ht treatment/session. |
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SIGNATURE:
DATE: |
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PARENT/GARDIAN SIGNATURE (IF UNDER 18YEARS)
DATE: |
