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Initial Massage Therapy Form
This form was developed to ensure all patrons are fully aware of rights, benefits, risks as well as letting your therapist know about the treatment you would like, your focus and most important your health history.
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* Indicates required question
Today's Date
*
Your answer
Full first and last name
*
Your answer
Birthday
*
MM
/
DD
/
YYYY
Address (street, city, postal code)
*
Your answer
Email
*
Your answer
Primary Contact Number
*
Your answer
Home Number
Your answer
Work Number
Your answer
Occupation
*
Your answer
What is your preferred method of communication?
*
Texting
Email
Phone Call (please specify number in "Other")
Other:
Required
Whom should we thank for referring you to us?
*
Driving By
Friend
Flyer
Magazine
Health Care Practitioner Referral
Event
Google
Other:
Required
Have you received massage therapy before?
*
Yes
No
Who is your primary care physician? Address?
*
(If you do not have a physician please enter N/A)
Your answer
Current Medication?
*
If YES type what medication and what it treats in the field marked "Other"
No
Yes
Other:
Required
Are you receiving treatment from another healthcare professional?
*
Acupunture
Chiropractor
Massage Therapist
Reflexology
Osteopath
Physiotherapy
None of the above
Other:
Required
If you answered YES to the last question, what is the treatment for?
Your answer
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