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PhysiYo Massage Intake/Consent Form

Birthday
Month
Day
Year
Multi-line address
Please indicate any of the following that apply to you currently or in the past:
What type of massage are you seeking?
What pressure do you prefer?

It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success or effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status.

I will participate fully as a member of my healthcare team. I will make sound choices regarding my sessions’ plan based upon the information provided by my massage therapist. I agree to participate in my own self-care programs and adhere to the plan we select. I agree to communicate with my practitioner any time I feel my well-being is being compromised. I expect my practitioner to provide safe and effective treatment to the best of his or her skills and knowledge.

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