Intake Form Tony George LMT

Full Name

First NameLast Name

E-mail

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

Occupation

Please list any medications

Height and Weight

Has a doctor told you NOT to recieve Massage Therapy?

Your reason for obtaining treatment

RelaxationPain or injury relief

Pregnant?

Do you presently have any skin conditions, or a contagious disease?

If yes please describe

Describe what your particular need is regarding Massage Therapy please be as detailed as possible

If you have had surgery, please list when, and what the surgery was

Please click any that apply

Please read before pressing SUBMIT.

Because Massage is contraindicated under certain conditions, I affirm I have stated all my medical conditions and answered all questions honestly. I agree to keep the Therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist's part should I forget to do so.

I also understand that the agreed to time period contracted runs from the time of the appointment to the end of the specified appointment and that if I am late I may lose time, but will still be responsible to pay the agrred to charge for the agreed to time period.

I understand that I am contracting Therapeutic Massage from licensed professional and that any inappropriate conduct toward the Therapist, during the session ,may end the session immediately and I will still be responsible to pay the agreed to price.

Please type your name in and electronically sign this intake form. This represents your agreement to the above statement. Then Click SUBMIT....Thanks