Medical History Form

Full Name

First NameLast Name

Pronoun preference?

Contact Number

Check the conditions that apply to you:

If yes to skin allergies, please list:

Any past surgeries? How long ago?

Have you been vaccinated for COVID-19?

YesNoPartiallyI am unable to vaccinate

Any other pertinent information to give? This can also be recent injuries or illnesses you have experienced.

We kindly ask you to read the following before submitting this form. Submitting this client registration form indicates that you have read and agree to the terms and conditions of privacy and other conditions set out.

I hereby declare that the information submitted through the Client Information Form is true and correct to the best of my knowledge and belief. Additionally, I am aware that therapeutic massage is non-sexual in nature, thus draping will be required at all times. I understand that should the client or therapist be made uncomfortable for any reason, either party may cease the massage and the session will end. I understand that massage is not a substitute for licensed medical examination and as such, the therapist cannot diagnose physical, mental or emotional illnesses; I am solely responsible for consulting with a qualified physician for any medical conditions I may have.

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