Massages form consent

Email(Required)

Phone(Required)

Are you taking any medications? If yes, please list:

Any allergies? (oils, lotions, nuts, fruits, skin, etc.)(Required)

Are you pregnant? If yes, how many months(Required)

Are you you currently under medical supervision or receiving other medical interventions? If yes, please describe:(Required)

Areas of broken skin? (e.g. rash, wounds) If yes, where?(Required)

History of joint replacement surgery?If yes, where?(Required)

Recent injuries or medical procedures in the past 2 years?(Required)

Please describe any other injuries or health conditions:(Required)

Have you had professional massage before? If yes how recently?(Required)

Reason for seeking massage?(Required)

Signature(Required)