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Returning Client Form
We are so happy to have you back with us.
Please fill out the brief form below.
Thank you for choosing Partner To Heal on your wellness journey.
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First Name
*
Your answer
Last Name
*
Your answer
Are you taking any
NEW
medications?
*
Yes
No
If you answered yes above, please list the medication.
Your answer
List any
NEW
medical issues (i.e. Injuries/surgeries since your last visit): if none, insert N/A.
*
Your answer
List any
PAIN
you may be experiencing today (i.e. back, neck shoulders head etc.):
*
Your answer
List any areas to be
AVOIDED
in this session:
*
Your answer
Desired level of pressure for this session.
*
Light
Light/Medium
Medium
Medium/Deep
Deep
I Have No Idea
I understand the benefits and risks of massage and give my consent for massage. Massage should not be performed under certain conditions. Understanding this I affirm that I have stated all my known medical conditions and answered all questions honestly. I will consult my practitioner with any further questions or concerns immediately.
*
I Agree
I Do Not Agree
Today's Date
*
MM
/
DD
/
YYYY
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