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Luna Beauty & Wellness
Client Intake Form – Therapeutic Massage

Draping will be used during the session – only the area being worked on will be uncovered.

Luna Beauty and Wellness reserves the right to refuse service. Any lewd/disrespectful/sexual/inappropriate comments or behavior will terminate the session and I will be liable for payment of the scheduled treatment. 

I agree and accept the 24 hour cancellation policy which states that a minimum of 24 hours’ notice must be given to cancel and/or reschedule an appointment. If I fail to do so I agree that I will pay Luna Beauty and Wellness the full amount for the service. If I have a gift certificate, voucher or membership credit intended for this service I agree to forfeit its value and pay the difference should there be a remaining balance.

I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension and I consent to this treatment. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said during the course the session given should be construed as such. Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I agree to keep Luna Beauty and Wellness and the therapist updated as to any changes in my medical profile and understand that there shall be no liability on Luna Beauty and Wellness or the therapist’s part should I fail to do so.

Today's date: September 28, 2021

First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Information

What are your preferred pronouns? *

Referred by *

Occupation *

The following information will be used to help plan safe and effective massage sessions. Please answer the questions to the best of your knowledge.

Have you had a professional massage before?*
No
Yes

If yes, how often?
Do you have any difficulty lying on your front, back, or side?*
No
Yes

If yes, please explain
Do you have sensitive skin and/or any allergies to oils, lotions, ointments, fragrances, fruits or nuts?*
No
Yes

If yes, please explain
Are you wearing:
a hair piece
contact lenses
hearing aid
dentures
prosthetics
Do you sit for long hours at a workstation, computer, or driving?*
No
Yes
Do you perform any repetitive movement in your work, sports, or hobby?*
No
Yes

If yes, please describe
Is there a specific area of your body where you are experiencing tension, stiffness, pain or discomfort?*
No
Yes

If yes, please describe
Is there any area of your body you'd like for me to avoid during our session?*
No
Yes

If yes, please identify

What are your goals for this session? *

Any specific areas you would like the massage therapist to concentrate on during the session:
Are you currently under medical supervision?*
No
Yes

If yes, please explain
Are you currently taking any medication?*
No
Yes

If yes, please list
Please check any condition below that applies to you:
allergies/sensitivity
artificial joint
autoimmune disease
atherosclerosis
back/neck problems
contagious skin condition
circulatory disorder
cancer
carpal tunnel syndrome
current fever
decreased sensation
epilepsy
recent surgery
recent fracture
recent sprains/strains
recent accident or injury
tennis elbow
TMJ
swollen glands
varicose veins
heart condition
high or low blood pressure
rheumatoid arthritis/ osteoarthritis/ tendonitis
deep vein thrombosis/ blood clots
phlebitis
open sores or wounds
pregnancy
fibromyalgia
joint disorder
diabetes
osteoporosis
easy bruising
headaches/ migraines

Please explain any condition that you have marked above

Is there anything else in your health history that you feel would be useful for your massage therapist to know to plan a safe and massage session for you?
First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Information

What are your preferred pronouns? *

Referred by *

Occupation *

The following information will be used to help plan safe and effective massage sessions. Please answer the questions to the best of your knowledge.

Have you had a professional massage before?*
No
Yes

If yes, how often?
Do you have any difficulty lying on your front, back, or side?*
No
Yes

If yes, please explain
Do you have sensitive skin and/or any allergies to oils, lotions, ointments, fragrances, fruits or nuts?*
No
Yes

If yes, please explain
Are you wearing:
a hair piece
contact lenses
hearing aid
dentures
prosthetics
Do you sit for long hours at a workstation, computer, or driving?*
No
Yes
Do you perform any repetitive movement in your work, sports, or hobby?*
No
Yes

If yes, please describe
Is there a specific area of your body where you are experiencing tension, stiffness, pain or discomfort?*
No
Yes

If yes, please describe
Is there any area of your body you'd like for me to avoid during our session?*
No
Yes

If yes, please identify

What are your goals for this session? *

Any specific areas you would like the massage therapist to concentrate on during the session:
Are you currently under medical supervision?*
No
Yes

If yes, please explain
Are you currently taking any medication?*
No
Yes

If yes, please list
Please check any condition below that applies to you:
allergies/sensitivity
artificial joint
autoimmune disease
atherosclerosis
back/neck problems
contagious skin condition
circulatory disorder
cancer
carpal tunnel syndrome
current fever
decreased sensation
epilepsy
recent surgery
recent fracture
recent sprains/strains
recent accident or injury
tennis elbow
TMJ
swollen glands
varicose veins
heart condition
high or low blood pressure
rheumatoid arthritis/ osteoarthritis/ tendonitis
deep vein thrombosis/ blood clots
phlebitis
open sores or wounds
pregnancy
fibromyalgia
joint disorder
diabetes
osteoporosis
easy bruising
headaches/ migraines

Please explain any condition that you have marked above

Is there anything else in your health history that you feel would be useful for your massage therapist to know to plan a safe and massage session for you?
Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Information

What are your preferred pronouns? *

Referred by *

Occupation *

The following information will be used to help plan safe and effective massage sessions. Please answer the questions to the best of your knowledge.

Have you had a professional massage before?*
No
Yes

If yes, how often?
Do you have any difficulty lying on your front, back, or side?*
No
Yes

If yes, please explain
Do you have sensitive skin and/or any allergies to oils, lotions, ointments, fragrances, fruits or nuts?*
No
Yes

If yes, please explain
Are you wearing:
a hair piece
contact lenses
hearing aid
dentures
prosthetics
Do you sit for long hours at a workstation, computer, or driving?*
No
Yes
Do you perform any repetitive movement in your work, sports, or hobby?*
No
Yes

If yes, please describe
Is there a specific area of your body where you are experiencing tension, stiffness, pain or discomfort?*
No
Yes

If yes, please describe
Is there any area of your body you'd like for me to avoid during our session?*
No
Yes

If yes, please identify

What are your goals for this session? *

Any specific areas you would like the massage therapist to concentrate on during the session:
Are you currently under medical supervision?*
No
Yes

If yes, please explain
Are you currently taking any medication?*
No
Yes

If yes, please list
Please check any condition below that applies to you:
allergies/sensitivity
artificial joint
autoimmune disease
atherosclerosis
back/neck problems
contagious skin condition
circulatory disorder
cancer
carpal tunnel syndrome
current fever
decreased sensation
epilepsy
recent surgery
recent fracture
recent sprains/strains
recent accident or injury
tennis elbow
TMJ
swollen glands
varicose veins
heart condition
high or low blood pressure
rheumatoid arthritis/ osteoarthritis/ tendonitis
deep vein thrombosis/ blood clots
phlebitis
open sores or wounds
pregnancy
fibromyalgia
joint disorder
diabetes
osteoporosis
easy bruising
headaches/ migraines

Please explain any condition that you have marked above

Is there anything else in your health history that you feel would be useful for your massage therapist to know to plan a safe and massage session for you?
Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Information

What are your preferred pronouns? *

Referred by *

Occupation *

The following information will be used to help plan safe and effective massage sessions. Please answer the questions to the best of your knowledge.

Have you had a professional massage before?*
No
Yes

If yes, how often?
Do you have any difficulty lying on your front, back, or side?*
No
Yes

If yes, please explain
Do you have sensitive skin and/or any allergies to oils, lotions, ointments, fragrances, fruits or nuts?*
No
Yes

If yes, please explain
Are you wearing:
a hair piece
contact lenses
hearing aid
dentures
prosthetics
Do you sit for long hours at a workstation, computer, or driving?*
No
Yes
Do you perform any repetitive movement in your work, sports, or hobby?*
No
Yes

If yes, please describe
Is there a specific area of your body where you are experiencing tension, stiffness, pain or discomfort?*
No
Yes

If yes, please describe
Is there any area of your body you'd like for me to avoid during our session?*
No
Yes

If yes, please identify

What are your goals for this session? *

Any specific areas you would like the massage therapist to concentrate on during the session:
Are you currently under medical supervision?*
No
Yes

If yes, please explain
Are you currently taking any medication?*
No
Yes

If yes, please list
Please check any condition below that applies to you:
allergies/sensitivity
artificial joint
autoimmune disease
atherosclerosis
back/neck problems
contagious skin condition
circulatory disorder
cancer
carpal tunnel syndrome
current fever
decreased sensation
epilepsy
recent surgery
recent fracture
recent sprains/strains
recent accident or injury
tennis elbow
TMJ
swollen glands
varicose veins
heart condition
high or low blood pressure
rheumatoid arthritis/ osteoarthritis/ tendonitis
deep vein thrombosis/ blood clots
phlebitis
open sores or wounds
pregnancy
fibromyalgia
joint disorder
diabetes
osteoporosis
easy bruising
headaches/ migraines

Please explain any condition that you have marked above

Is there anything else in your health history that you feel would be useful for your massage therapist to know to plan a safe and massage session for you?
Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Information

What are your preferred pronouns? *

Referred by *

Occupation *

The following information will be used to help plan safe and effective massage sessions. Please answer the questions to the best of your knowledge.

Have you had a professional massage before?*
No
Yes

If yes, how often?
Do you have any difficulty lying on your front, back, or side?*
No
Yes

If yes, please explain
Do you have sensitive skin and/or any allergies to oils, lotions, ointments, fragrances, fruits or nuts?*
No
Yes

If yes, please explain
Are you wearing:
a hair piece
contact lenses
hearing aid
dentures
prosthetics
Do you sit for long hours at a workstation, computer, or driving?*
No
Yes
Do you perform any repetitive movement in your work, sports, or hobby?*
No
Yes

If yes, please describe
Is there a specific area of your body where you are experiencing tension, stiffness, pain or discomfort?*
No
Yes

If yes, please describe
Is there any area of your body you'd like for me to avoid during our session?*
No
Yes

If yes, please identify

What are your goals for this session? *

Any specific areas you would like the massage therapist to concentrate on during the session:
Are you currently under medical supervision?*
No
Yes

If yes, please explain
Are you currently taking any medication?*
No
Yes

If yes, please list
Please check any condition below that applies to you:
allergies/sensitivity
artificial joint
autoimmune disease
atherosclerosis
back/neck problems
contagious skin condition
circulatory disorder
cancer
carpal tunnel syndrome
current fever
decreased sensation
epilepsy
recent surgery
recent fracture
recent sprains/strains
recent accident or injury
tennis elbow
TMJ
swollen glands
varicose veins
heart condition
high or low blood pressure
rheumatoid arthritis/ osteoarthritis/ tendonitis
deep vein thrombosis/ blood clots
phlebitis
open sores or wounds
pregnancy
fibromyalgia
joint disorder
diabetes
osteoporosis
easy bruising
headaches/ migraines

Please explain any condition that you have marked above

Is there anything else in your health history that you feel would be useful for your massage therapist to know to plan a safe and massage session for you?
Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Information

What are your preferred pronouns? *

Referred by *

Occupation *

The following information will be used to help plan safe and effective massage sessions. Please answer the questions to the best of your knowledge.

Have you had a professional massage before?*
No
Yes

If yes, how often?
Do you have any difficulty lying on your front, back, or side?*
No
Yes

If yes, please explain
Do you have sensitive skin and/or any allergies to oils, lotions, ointments, fragrances, fruits or nuts?*
No
Yes

If yes, please explain
Are you wearing:
a hair piece
contact lenses
hearing aid
dentures
prosthetics
Do you sit for long hours at a workstation, computer, or driving?*
No
Yes
Do you perform any repetitive movement in your work, sports, or hobby?*
No
Yes

If yes, please describe
Is there a specific area of your body where you are experiencing tension, stiffness, pain or discomfort?*
No
Yes

If yes, please describe
Is there any area of your body you'd like for me to avoid during our session?*
No
Yes

If yes, please identify

What are your goals for this session? *

Any specific areas you would like the massage therapist to concentrate on during the session:
Are you currently under medical supervision?*
No
Yes

If yes, please explain
Are you currently taking any medication?*
No
Yes

If yes, please list
Please check any condition below that applies to you:
allergies/sensitivity
artificial joint
autoimmune disease
atherosclerosis
back/neck problems
contagious skin condition
circulatory disorder
cancer
carpal tunnel syndrome
current fever
decreased sensation
epilepsy
recent surgery
recent fracture
recent sprains/strains
recent accident or injury
tennis elbow
TMJ
swollen glands
varicose veins
heart condition
high or low blood pressure
rheumatoid arthritis/ osteoarthritis/ tendonitis
deep vein thrombosis/ blood clots
phlebitis
open sores or wounds
pregnancy
fibromyalgia
joint disorder
diabetes
osteoporosis
easy bruising
headaches/ migraines

Please explain any condition that you have marked above

Is there anything else in your health history that you feel would be useful for your massage therapist to know to plan a safe and massage session for you?
Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Information

What are your preferred pronouns? *

Referred by *

Occupation *

The following information will be used to help plan safe and effective massage sessions. Please answer the questions to the best of your knowledge.

Have you had a professional massage before?*
No
Yes

If yes, how often?
Do you have any difficulty lying on your front, back, or side?*
No
Yes

If yes, please explain
Do you have sensitive skin and/or any allergies to oils, lotions, ointments, fragrances, fruits or nuts?*
No
Yes

If yes, please explain
Are you wearing:
a hair piece
contact lenses
hearing aid
dentures
prosthetics
Do you sit for long hours at a workstation, computer, or driving?*
No
Yes
Do you perform any repetitive movement in your work, sports, or hobby?*
No
Yes

If yes, please describe
Is there a specific area of your body where you are experiencing tension, stiffness, pain or discomfort?*
No
Yes

If yes, please describe
Is there any area of your body you'd like for me to avoid during our session?*
No
Yes

If yes, please identify

What are your goals for this session? *

Any specific areas you would like the massage therapist to concentrate on during the session:
Are you currently under medical supervision?*
No
Yes

If yes, please explain
Are you currently taking any medication?*
No
Yes

If yes, please list
Please check any condition below that applies to you:
allergies/sensitivity
artificial joint
autoimmune disease
atherosclerosis
back/neck problems
contagious skin condition
circulatory disorder
cancer
carpal tunnel syndrome
current fever
decreased sensation
epilepsy
recent surgery
recent fracture
recent sprains/strains
recent accident or injury
tennis elbow
TMJ
swollen glands
varicose veins
heart condition
high or low blood pressure
rheumatoid arthritis/ osteoarthritis/ tendonitis
deep vein thrombosis/ blood clots
phlebitis
open sores or wounds
pregnancy
fibromyalgia
joint disorder
diabetes
osteoporosis
easy bruising
headaches/ migraines

Please explain any condition that you have marked above

Is there anything else in your health history that you feel would be useful for your massage therapist to know to plan a safe and massage session for you?
Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Information

What are your preferred pronouns? *

Referred by *

Occupation *

The following information will be used to help plan safe and effective massage sessions. Please answer the questions to the best of your knowledge.

Have you had a professional massage before?*
No
Yes

If yes, how often?
Do you have any difficulty lying on your front, back, or side?*
No
Yes

If yes, please explain
Do you have sensitive skin and/or any allergies to oils, lotions, ointments, fragrances, fruits or nuts?*
No
Yes

If yes, please explain
Are you wearing:
a hair piece
contact lenses
hearing aid
dentures
prosthetics
Do you sit for long hours at a workstation, computer, or driving?*
No
Yes
Do you perform any repetitive movement in your work, sports, or hobby?*
No
Yes

If yes, please describe
Is there a specific area of your body where you are experiencing tension, stiffness, pain or discomfort?*
No
Yes

If yes, please describe
Is there any area of your body you'd like for me to avoid during our session?*
No
Yes

If yes, please identify

What are your goals for this session? *

Any specific areas you would like the massage therapist to concentrate on during the session:
Are you currently under medical supervision?*
No
Yes

If yes, please explain
Are you currently taking any medication?*
No
Yes

If yes, please list
Please check any condition below that applies to you:
allergies/sensitivity
artificial joint
autoimmune disease
atherosclerosis
back/neck problems
contagious skin condition
circulatory disorder
cancer
carpal tunnel syndrome
current fever
decreased sensation
epilepsy
recent surgery
recent fracture
recent sprains/strains
recent accident or injury
tennis elbow
TMJ
swollen glands
varicose veins
heart condition
high or low blood pressure
rheumatoid arthritis/ osteoarthritis/ tendonitis
deep vein thrombosis/ blood clots
phlebitis
open sores or wounds
pregnancy
fibromyalgia
joint disorder
diabetes
osteoporosis
easy bruising
headaches/ migraines

Please explain any condition that you have marked above

Is there anything else in your health history that you feel would be useful for your massage therapist to know to plan a safe and massage session for you?
Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Information

What are your preferred pronouns? *

Referred by *

Occupation *

The following information will be used to help plan safe and effective massage sessions. Please answer the questions to the best of your knowledge.

Have you had a professional massage before?*
No
Yes

If yes, how often?
Do you have any difficulty lying on your front, back, or side?*
No
Yes

If yes, please explain
Do you have sensitive skin and/or any allergies to oils, lotions, ointments, fragrances, fruits or nuts?*
No
Yes

If yes, please explain
Are you wearing:
a hair piece
contact lenses
hearing aid
dentures
prosthetics
Do you sit for long hours at a workstation, computer, or driving?*
No
Yes
Do you perform any repetitive movement in your work, sports, or hobby?*
No
Yes

If yes, please describe
Is there a specific area of your body where you are experiencing tension, stiffness, pain or discomfort?*
No
Yes

If yes, please describe
Is there any area of your body you'd like for me to avoid during our session?*
No
Yes

If yes, please identify

What are your goals for this session? *

Any specific areas you would like the massage therapist to concentrate on during the session:
Are you currently under medical supervision?*
No
Yes

If yes, please explain
Are you currently taking any medication?*
No
Yes

If yes, please list
Please check any condition below that applies to you:
allergies/sensitivity
artificial joint
autoimmune disease
atherosclerosis
back/neck problems
contagious skin condition
circulatory disorder
cancer
carpal tunnel syndrome
current fever
decreased sensation
epilepsy
recent surgery
recent fracture
recent sprains/strains
recent accident or injury
tennis elbow
TMJ
swollen glands
varicose veins
heart condition
high or low blood pressure
rheumatoid arthritis/ osteoarthritis/ tendonitis
deep vein thrombosis/ blood clots
phlebitis
open sores or wounds
pregnancy
fibromyalgia
joint disorder
diabetes
osteoporosis
easy bruising
headaches/ migraines

Please explain any condition that you have marked above

Is there anything else in your health history that you feel would be useful for your massage therapist to know to plan a safe and massage session for you?
Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Information

What are your preferred pronouns? *

Referred by *

Occupation *

The following information will be used to help plan safe and effective massage sessions. Please answer the questions to the best of your knowledge.

Have you had a professional massage before?*
No
Yes

If yes, how often?
Do you have any difficulty lying on your front, back, or side?*
No
Yes

If yes, please explain
Do you have sensitive skin and/or any allergies to oils, lotions, ointments, fragrances, fruits or nuts?*
No
Yes

If yes, please explain
Are you wearing:
a hair piece
contact lenses
hearing aid
dentures
prosthetics
Do you sit for long hours at a workstation, computer, or driving?*
No
Yes
Do you perform any repetitive movement in your work, sports, or hobby?*
No
Yes

If yes, please describe
Is there a specific area of your body where you are experiencing tension, stiffness, pain or discomfort?*
No
Yes

If yes, please describe
Is there any area of your body you'd like for me to avoid during our session?*
No
Yes

If yes, please identify

What are your goals for this session? *

Any specific areas you would like the massage therapist to concentrate on during the session:
Are you currently under medical supervision?*
No
Yes

If yes, please explain
Are you currently taking any medication?*
No
Yes

If yes, please list
Please check any condition below that applies to you:
allergies/sensitivity
artificial joint
autoimmune disease
atherosclerosis
back/neck problems
contagious skin condition
circulatory disorder
cancer
carpal tunnel syndrome
current fever
decreased sensation
epilepsy
recent surgery
recent fracture
recent sprains/strains
recent accident or injury
tennis elbow
TMJ
swollen glands
varicose veins
heart condition
high or low blood pressure
rheumatoid arthritis/ osteoarthritis/ tendonitis
deep vein thrombosis/ blood clots
phlebitis
open sores or wounds
pregnancy
fibromyalgia
joint disorder
diabetes
osteoporosis
easy bruising
headaches/ migraines

Please explain any condition that you have marked above

Is there anything else in your health history that you feel would be useful for your massage therapist to know to plan a safe and massage session for you?
Client's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
I confirm that I have read and understand all information on the applicable forms for this treatment or service and accept responsibility on my child’s behalf for any disclosures or liability described on those forms. I agree and give permission for my child to have the above services performed today and going forward as needed. I agree to supervise any home care procedures that are recommended as a result of the treatment. Clients under the age of 18 must be accompanied by a parent or legal guardian during the entire session. Informed written consent must be provided by parent or legal guardian for any client under the age of 18.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

What are your preferred pronouns? *

Referred by *

Occupation *

The following information will be used to help plan safe and effective massage sessions. Please answer the questions to the best of your knowledge.

Have you had a professional massage before?*
No
Yes

If yes, how often?
Do you have any difficulty lying on your front, back, or side?*
No
Yes

If yes, please explain
Do you have sensitive skin and/or any allergies to oils, lotions, ointments, fragrances, fruits or nuts?*
No
Yes

If yes, please explain
Are you wearing:
a hair piece
contact lenses
hearing aid
dentures
prosthetics
Do you sit for long hours at a workstation, computer, or driving?*
No
Yes
Do you perform any repetitive movement in your work, sports, or hobby?*
No
Yes

If yes, please describe
Is there a specific area of your body where you are experiencing tension, stiffness, pain or discomfort?*
No
Yes

If yes, please describe
Is there any area of your body you'd like for me to avoid during our session?*
No
Yes

If yes, please identify

What are your goals for this session? *

Any specific areas you would like the massage therapist to concentrate on during the session:
Are you currently under medical supervision?*
No
Yes

If yes, please explain
Are you currently taking any medication?*
No
Yes

If yes, please list
Please check any condition below that applies to you:
allergies/sensitivity
artificial joint
autoimmune disease
atherosclerosis
back/neck problems
contagious skin condition
circulatory disorder
cancer
carpal tunnel syndrome
current fever
decreased sensation
epilepsy
recent surgery
recent fracture
recent sprains/strains
recent accident or injury
tennis elbow
TMJ
swollen glands
varicose veins
heart condition
high or low blood pressure
rheumatoid arthritis/ osteoarthritis/ tendonitis
deep vein thrombosis/ blood clots
phlebitis
open sores or wounds
pregnancy
fibromyalgia
joint disorder
diabetes
osteoporosis
easy bruising
headaches/ migraines

Please explain any condition that you have marked above

Is there anything else in your health history that you feel would be useful for your massage therapist to know to plan a safe and massage session for you?
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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