Hold Harmless Agreement: I understand that feedback is essential

We are here to nurture you. If you feel any discomfort, please feel at ease in letting us know

Client Name

Date of Birth Gender

Phone Email

Address

How did you hear about us __________________________________________________________

Have you ever had any major illnesses, injuries, or surgeries? If so, explain:

Also, please circle any conditions; current or past.

Muscle or joint pain Numbness/Tingling Contagious diseases

Bruise easily High/Low blood pressure Stroke, heart attack

Varicose veins/Blood clots Shortness of breath, asthma Cancer

Neurological Epilepsy/Seizures Headache/Migraines

Dizziness Sciatica Spinal injuries/Scoliosis

Broken bones Allergies Trauma

Diabetes Arthritis (rheumatoid/osteo) Dental history

Other (please explain):

What are your expectations today?

How do you feel today?

Are you under the care of a health professional?

List all medications and supplements that you currently take:

Occupation and hobbies:

Women only: Are you pregnant? How many weeks?

Hold Harmless Agreement:

I understand that feedback is essential during massage. It is my responsibility to discuss

all physical conditions and inform the therapist of any changes after the initial session. I

understand that massage involves neither diagnosis nor treatment of any condition, and

is not a substitute for my medical care. Session(s) will consist of Therapeutic massage and

draping will be used at all times. I hereby release, waive, covenant not to sue, discharge,

and hold harmless Living Tree Wellness, its agents, contracted therapists, and

representatives.

Signature____________________________________________________ Date___________________

(Parent or guardian if under the age of 18)