Health and Safety Form Name(Required) First Last Phone(Required)Email(Required) Date of Birth(Required) MM slash DD slash YYYY Address(Required) Street Address Address Line 2 City ZIP / Postal Code How would you rate your general health?(Required) Excellent Good Fair Poor Are you pregnant?(Required) Yes No Have you had a professional massage before?(Required) Yes No List current medications & the conditions they are treating(Required) List any major accidents or surgeries (including dates)(Required) Consent(Required)It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status. I understand that my personal health information will be collected. I understand that all information that I provide will be kept confidential unless required by law. I agree and would like to proceed with my treatment.PhoneThis field is for validation purposes and should be left unchanged.
