Your Full First & Last Name: *
I have honestly stated all my pertinent medical conditions, and will update the massage therapist of any changes in my health status prior to receiving further care. * Yes
I understand that treatments are designed to address the care and prevention of myofascial pain and dysfunction. * Yes
It is my choice to receive therapeutic massage as a form of health care therapy. * Yes
I understand that massage therapists do not diagnose illness, disease, physical or mental disorders, prescribe medical treatment or pharmaceuticals, nor do they perform joint mobilization or any sexual acts. * Yes
I acknowledge that massage therapy is not a substitute for medical examination or diagnosis, and it is recommended that I collaborate with a physician for that service. * Yes
Permission to consult with your current physician? * Yes No
Signature: *
Date: *
