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Forms

MIRAGE Salon & MedSpa

Massage Therapy Health Questionnaire

Client Information

Sex
Male
Female
Birthday
Month
Day
Year
Have you ever received a professional massage or bodywork before?
Yes
No
Are you currently under the care of a physician?
Yes
No
The following information is required to determine if massage therapy is safe. These conditions or diseases may be aggravated by massage therapy. Please identify those you are currently experiencing.
Are you taking any medications?
Yes
No
What is the reason for receiving massage today?

Please take note that massage therapy should not be a substitute for medical examinations, diagnosis, or treatment.  I should see a physician, chiropractor, or any other medical specialist for any medical changes.  I understand that any illicit or sexually suggestive advances or remarks made by me will result in termination of the session and I will be liable for payment of the scheduled appointment.  If for some reason I cannot keep my appointment, I will notify the therapist as soon as possible.

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