An accurate health history is important to ensure that it is safe for you to receive treatment. If your health status changes in the future please let us know. All information gathered is confidential except as required by law. You will be asked to provide written authorization for release of any information.

Name *
Name
Address *
Address
Date of Birth *
Date of Birth
Phone/Cell *
Phone/Cell
Cardiovascular
Please indicate conditions you are experiencing or have experienced.
Respiratory
Head/Neck
Soft Tissue/Joints
Infections
Other Conditions
Women
Skin
Massage Therapy involves the manipulation of the soft tissues of the body, skin, muscle, ligaments and connective tissues, using techniques to produce therapeutic results. With Massage Therapy the client disrobes to their comfort level, and lies on a table between two sheets. Only the area of the body being directly treated are uncovered at one time. If at any time you are uncomfortable with the pressure or technique being used, you can tell the therapist (ie. to decrease or increase pressure, irritating, etc.) You can also stop the treatment at any time. There is a 24 hour cancellation policy on any appointments made. Please inform us on any changes with your schedule to avoid any charges. I have read the above and give consent for treatment.