Informed Consent: Massage Therapy
This form must be completed prior to your first massage appointment, and annually thereafter.
Sign in to Google to save your progress. Learn more
Email *
First name *
Last name *
Name you go by *
Have you received a professional massage before? *
What is your main goal for this treatment?
*
Do you experience chronic stress in your
*
How often do you exercise?
*
What types of physical activities do you regularly participate in?
*
Describe any repetitive movement involved in your work, sports, or hobbies.
Do you sit for long hours at a
*
Required
Explain. *
Are you experiencing
*
Required
Explain. *
List and explain any injuries, surgeries, or areas of inflammation.
*
List any medications you are currently taking.
*
Do you have sensitive skin?
*
List any known allergies. (oils, lotions, ointments, herbs, foods, etc.)
*
Are you currently under the care of a physician for any reason?
*
If so, why?
*

Place an "X" next to any of the following conditions you are currently experiencing or have experienced in the past.

*
Required
Please explain any of the conditions that you have marked above.
*
Any other medical condition(s) not listed? (Write n/a if none.)
*

I understand and agree to the following (check each box):

*
Required
*
MM
/
DD
/
YYYY
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Poplar Creek Spa. Report Abuse