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If My Mind Can Conceive It & My Heart Can Believe It,
THEN I CAN ACHIEVE IT!
- Muhammad Ali
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New Massage Therapy Information Form
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Name
*
First
Last
Date Of Birth
Email
*
Phone
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
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Virgin Islands, U.S.
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Country
Name of Family Dr.
Family Dr. Phone Number
Primary areas of concern
(ie shoulders/neck/low back)
HEALTH HISTORY:
Please indicate conditions you are experiencing, or have experienced
Chronic cough
Shortness of breath
Bronchitis
Asthma
Heart Attack
Hearing
Hepatitis
TB
Sensitive Skin
Loss of sensation
Diabetes
Epilepsy
High Blood Pressure
Ear problems
Pacemaker
Rashes / Uticaria
HIV
Pregnant
Allergies
Emphysema
Low Blood Pressure
Arthritis
Bruise Easily
Skin conditions
Phlebitis
Vision Problems
Other Health Concerns
Please list any other health issues that may not be indicated above.
Current Medications
Present Involvement in other Health Care
Special Notes:
Agreement
*
By digitally signing this document I agree to the following: Hereby grant the Registered Massage Therapist permission to initiate the assessment and rehabilitation protocols necessary for the treatment of my injury or injuries. Give permission to Registered Massage Therapist to obtain any form of medical documentation relating to my injury and or condition, such as, (but not limited to) x-ray reports, MRI reports and CT scan reports.
I understand and agree to the terms above.
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