I have stated all conditions that I am aware of and this information is true and accurate.  I will inform the heath care provider of any changes in my status.  I also understand that Kimberly Stumpf, LMT is NOT a doctor and will work only within that scope of practice, Massage Therapy, working with muscle, pain management, and relaxation.  

I understand the treatement I am going to be receiving, and understand that this is not an attempt to diagnosis a illiness or disorder.  It is further understood that I will keep my Primary Care Physician and any other medical professional aware of any and all physical or mental changes during my care with Kimberly Stumpf, LMT.  

I have stated all my medical conditions and am aware that this practitioner is not a allopathic or alternative physician.