Health History

When was your last massage treatment? List current medications and the conditions they are treating List any major accidents or surgeries (including dates) Please tell us about any allergies or hypersensitivities How were you referred to us?

Health Conditions

Consent & Policies

I hereby state that, to the best of my knowledge, my answers on all forms are correct.

I agree and consent to assessment and treatment. 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 understand and consent that my medical information may be shared by the various care providers involved in my care and treatment.

Treatments may be covered by extended health care plans. I understand that it is my responsibility to confirm the exact details of my coverage.

I have read and agree to the terms, statements & policies above *

Please sign your name below

I adopt the above as my signature *