Consent Form - Faithfully Therapeutic

First Name*

Last Name*

Birth Date*

Age*

Address*

Zip Code*

Contact No.*

Email Address*

Do you prefer no talking in your service?

Yes
No

What kind of pressure do you prefer?*

Light
Medium
Firm

Last professional massage?*

List the medications you currently take:

Are you pregnant?

Yes
No

How far long?*

Have you had any injuries or surgeries that may influence today's treatment?

Yes
No

If YES, how?*

Choose any of the following health conditions that you CURRENTLY have or have had in the past. Please answer honestly, as massage may cause harm if the below conditions apply.

Explain:

Consent for Treatment
I, , understand that the massage I am about to receive is solely for the purpose of relaxation....

*

I agree to and understand the above mentioned terms and conditions.
By submitting this form, I give my consent to receive care.