Pre-Treatment Health Declaration

Please fill out the following health declaration form in order to participate in treatment with any of our therapists.

Personal Information

First Name

Last Name

Select an Address

Phone

Birthday

Occupation

Medical Information

Do you suffer from any of the following:

Cancer, Headaches/Migraines, Arthritis, Diabetes, Joint Replacement(s), High/Low Blood Pressure, Neuropathy, Fibromyalgia, Stroke, Heart Attack, Kidney Disfunction, Blood Clots, Numbness, Sprains / Strains ?

Are you currently pregnant?

(If yes please detail how far along and any risk factors below)

Do you suffer with chronic pain?

(If yes please detail below and explain what makes it better / worse.)

If you answered "YES" to any of the above please note and detail below.

Massage Information

Please detail below your injuries and / or areas you wish for your therapist to work on and what you wish to achieve from your treatment.

By ticking this box you confirm that you have completed the form to the best of your ability and knowledge and you agree to inform your therapist if any of the above information changes at any time.

Thanks for submitting!