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Client Intake
Medical History and Agreement
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Name *
Address *
Telephone *
Birthdate *
MM
/
DD
/
YYYY
Occupation *
Please read carefully.
Massage Therapy is contra-indicated for certain medical conditions.
Check all that apply: *
Required
Please explain any conditions checked above. *
Please list any medications you are currently taking. *
All questions have been answered honestly to the best of my knowledge. *
I understand that my failure to share medical information releases all liability from my practitioner. *
I understand and agree to the 24 hour Cancellation Policy. *
I understand and agree to the No Tolerance Policy. *
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