Massage Therapy Form
Therapists: Anastasiia Blasko & Stefan Blasko
Client Information
Name
*
First Name
Last Name
Age
*
Date of Birth
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Details
In case of emergency, we will contact the person below:
Emergency Contact Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Relationship
Health Data
Do you have any allergies?
*
If yes, please specify on the field above.
Are you currently taking any medications?
*
If yes, please specify on the field above.
Are you pregnant or nursing? (Female only)
*
If yes, please specify on the field above.
Have you been recently hospitalized?
*
If yes, please specify on the field above.
Do you have any current injuries ; discs herniation or chronic pain?
*
If yes, please specify on the field above.
Please specify a Location of painful areas you want to relax during a massage session?
*
Current medical conditions like Asthma, Diabetes, Heart problems, Kidney problems, epilepsy, scoliosis, communicable disease, etc.?
*
Consent and Waiver
Please mark:
*
I authorize this massage therapist to perform the treatment or necessary procedure for me.
I authorize the use of lotion or oil to my body.
I understand that I should consult my doctor before the procedure and in case of a chronic pain in my body, I should deal with it first.
I understand that this is a relaxing alternative treatment and if there are any medical concerns, I need to talk to my physician.
I acknowledge that this massage therapy has no sexual intent and touching the therapist is strictly prohibited.
I release this massage therapists for any responsibility in case of an accident, illness, or injury.
I acknowledge that all information I provided int his form is true and accurate.
Signature of the Client
Date Signed
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: