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Massage form
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Name
*
First
Last
Email
*
Phone Number
Checkboxes
Light
Medium
Firm
Where would you like the therapist to focus on?
Occupation
Please list any medication and reason for taking.
Please provide any further details of any surgery/conditions we should know about that you have had in the last 2 years.
Are you pregnant?
Yes
No
Cancellation
Client Acknowledgement
I understand the benefits and risks of massage, cupping and dry needling & give my consent for these treatments. I also acknowledge it is my responsibility to answer all questions honestly and to inform the therapists of any changes to my health between visits.
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