Health declaration

Please fill out the following form.

First name

Last name

Address

Date of birth

Month

Day

Year

Emergency contact name and number

Physician name and number

Have you had a professional massage before?

Yes

Are you suffering from a medical condition, illness or injury?

Yes

If you answered yes to any of the questions above, please supply additional information (i.e. date, condition, injury type, etc.)

I consent to receive massage/craniosacral therapy and acknowledge it is not a substitute for medical care. I am aware of the potential benefits and risks, and understand that results are not guaranteed. I have provided an accurate health history and will inform my therapist of any changes. I consent to the collection of my personal health information, understanding it will be kept confidential unless release is required by law or for coordination with other healthcare providers.

Health declaration

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