Massage Consent & Waiver

    Birth Date:
    Today's Date:
    Reason for Massage:
    Please list any physical activities and/or sports that you do on a regular basis:
    Please specify if there are any body parts or areas that you’d like the massage therapist to focus on:
    If you are currently receiving treatment from any other health care professional (physician, physical therapist, naturopath, chiropractor, acupuncturist, etc.), please list them:
    Please list any medications that you are currently taking:
    Please list any surgeries that you’ve had in the past 5 years:
    Please indicate by checking the box if you have or have had any of the following physical conditions:
    (If checked, what is your due date?)
    (If checked, when did this occur?)