Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Do you suffer from back pain? *

please check all that apply

Upper

Middle

Lower

None

Have you ever received? *

please check all that apply

Massage Therapy

Energy Work

Foot Reflexology

Psoas Stretching

Cupping Therapy

Myofascial Release

None of the Above

I understand that the massage therapist is providing services within their scope of practice as defined by the American Massage Therapy Association. The therapist is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness. I have notified my therapist of all known medical conditions and injuries. Should my medical conditions change in the next twelve months from date of signing this, I will notify my therapist before future sessions. If I experience pain or discomfort during the session, I will immediately inform my therapist so the treatment can be adjusted to my comfort level.

I agree

Date *

MM

DD

YYYY