CONSULTATION FORM

Full Name*

Date of Birth*

Day

Month

Year

Phone*

Emergency Contact (Name & Phone Number)

Health Information

Please check all that apply

High/Low Blood Pressure

Heart Conditions

Diabetes

Skin Conditions

Pregnancy

Claustrophobia

Other

Do you have any injuries, tension, or areas of discomfort we should be aware of?

Please Specify

Please Specify

No

Yes

Please explain

I confirm that the above information is accurate to the best of my knowledge.

I understand that massage therapy is not a substitute for medical treatment.

I release the therapist and business from any liability if I withhold health information.

I will inform the therapist of any discomfort or changes during the session.

Any illicit or sexually suggestive behavior will result in immediate termination of the session, and full payment will still apply.

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