Kindly print and complete the Consent Form below and bring it with you to your first session. Thank you.
Client Medical History/Informed Consent Agreement
Name___________________DOB______Phone_____________
Address_____________________________________________
Email_______________________________________________
Any Serious Medical Condition(s)/Surgeries/Injuries/Accidents? incl. date(s)
____________________________________________________
If Cancer: Type_______________Site______________When____________
Radiation?___Lymph Nodes Removed/Irradiated? Where?_______________
Medical Appliances?________________________________
Any Pain/Soreness?______Where?_____How long?_______
Where on Pain Scale?1 2 3 4 5 6 7 8 9 10 (1=minor/10=extreme)
What makes pain worse?_____________________________
What makes it better?_______________________________ Medication(s)?_____________________________________
Any Skin Allergies/Reactions to Lotions, Oils, etc?______________________________________________
Anything you wish to add to help me ensure your session is safe, effective and enjoyable?
_________________________________________________
I understand that the massage given to me by JOHANNA M. SHANNON is for stress reduction, pain reduction, relief from muscle tension, and increasing circulation. I understand that the massage therapist does not diagnose illness or disease and does not prescribe medical treatment or pharmaceuticals, nor are spinal manipulations part of massage therapy. I understand that massage therapy is not a substitute for medical care and that it is recommended that I work with my primary caregiver for any condition I may have. I have stated all my known physical conditions and medications, and I will keep the massage therapist updated on any changes.
I understand all information will be kept confidential.
Signature_________________________Date_____________