Name
Phone
Email
Emergency Contact
Name of Primary Care Physician
Address of primary care physician
Have you received massage therapy before?
Are you currently receiving treatment from another health care professional?
If so, for what?
Overall, how is your general health?
What is the primary reason you are seeking massage therapy? Indicate the location or any tissue or joint discomfort:
Have you experienced loss of sensation? If so, where?
Are there any areas you would like NOT massaged?
Allergies?
Women | Pregnant, due:
Women | Gynaecological conditions Specify:
Past Accidents/Fractures/Surgeries
If Yes, Specify:
If Yes, What?
If Yes, Where?
Current Medications:
Current Medications: Current Conditions:
Disclaimer
I understand that massage therapy involves the manipulation of soft tissues and joints of the body in order to develop,
maintain, rehabilitate, improve physical function, or relieve pain
CONSENT
I hereby request and consent to the performance of massage therapy, reflexology treatment, and other soft tissue
procedures, including various forms of massage therapy, hydrotherapy, range of motion and orthopedic testing by the
Therapist.
I understand that I will have the opportunity to discuss my treatment with my Therapist. I also understand that results
are not guaranteed. I further understand and am informed that in the practice of massage therapy, as in all health
care, there are some slight risks to the treatment, including but not limited to: muscle tenderness, stiffness, and
sometimes bruising. I do not expect the Therapist to be able to anticipate all the risks and complications associated
with my treatment. I wish to rely on the Therapist to exercise judgement during the course of my treatment(s) to
apply the methods which he/she feels at the time, based on the facts known, and are in my best interest.
By signing below, I am signifying my agreement to massage therapy and I intend this consent to apply to and cover
the entire course of my treatment(s) with Kaizen Health Group.
Signature
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