Confidedntal Health History Form

Confidential Health History Form

Please indicate the appropriate level for each of the following:

Please indicate the appropriate level for each of the following:

Please go back into your personal history and include as many occurrences as possible for any of the following questions, the further back you can go the better we can understand how best to help you:

BY SIGNING BELOW, I ACKNOWLEDGE UNDERSTANDING OF AND AGREEMENT TO THE FOLLOWING:

CANCELLATION POLICY: Should I be unable to make it to a scheduled appointment, it is my responsibility to call and cancel this appointment. I will provide at least a 24-hour notice. Missing appointments or canceling appointments at the last minute will result in a fee of the full price of the scheduled massage.

• The massage therapists at Hands on Healing must be aware of any existing physical conditions I may have; therefore, I have listed all of these issues and I agree to inform my therapist(s) of any change(s) in my health. I understand that massage therapists do not diagnose illness, disease, or any physical or mental disorder, nor do they prescribe medical treatment or pharmaceuticals or perform spinal thrust manipulations. I acknowledge that massage is not a substitute for medical examination or diagnosis, and that it is recommended that I see a medical doctor for these services. I agree to communicate with my therapist any time I feel that my wellbeing is compromised.

• I give permission to receive appointment reminders via phone call, email, or text messages.

I UNDERSTAND THAT MY SESSION(S) ARE STRICTLY ETHICAL AND THERAPEUTIC. IMPROPER BEHAVIOR

WILL NOT BE PERMITTED. SHOULD IMPROPER BEHAVIOR OCCUR, MY SESSION(S) WILL BE DISCONTINUED IMMEDIATELY AND PAYMENT IN FULL WILL BE RENDERED.

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