Gender Male Female
Have you had a massage before? YES NO
Are you receiving treatment from any other health care professional? Physician Physical Therapist Naturopath Chircopractor Acupuncture
Infectious Conditions (present today)
Skin Conditions (non-contagious)
Please inform your therapist if you are currently experiencing a “flare-up” of any infectious condition.
Head & Neck
Respiratory Asthma Bronchitis Emphysema Chronic cough Shortness of breath Allergies
Muscle | Joint | Bone Rheumatoid arthritis Scoliosis Fractures/sprains Osteoporosis Wires/plates/pins Osteoarthritis
Pregnancy complications Menstrual problems Menopausal problems Gynecological problems
Has your doctor prescribed having a massage? YES NO
I understand that the massage that I receive is provided for the basic purpose of relaxation, stress reduction and relief of muscular tension. I further understand that massage should not be construed as a substitute for the medical examination, diagnosis or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any physical ailment that I am aware of. I understand that massage therapists are not qualified to perform skeletal adjustments, diagnose and/or prescribe, and that nothing said in the course of the session should be constructed as such. Because massage is contradicted under certain conditions, I affirm that I have stated all my known medical conditions and answered all the questions honestly. I agree to keep the therapists updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I do so. It is understood that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment for the full scheduled appointment. Please note we have a minimum 2-hour cancellation policy for all appointments, if the 2 hours is not met and you need to cancel, you are responsible for 100% of the missed appointments. All missed appointments must be paid in full before future services may be rendered. All patrons must be over the age of 18 years OR have all forms signed by a parent or legal guardian.
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Document Name: RMT
Agree & Sign