Date *

MM

DD

YYYY

Name *

First Name

Last Name

Phone *

(###)

###

####

Have you consumed alcohol in the last two hours? *

Yes

No

Check all conditions that you are affected by: *

Abdominal Pain

Allergies

Blood Clots

Spinal Problems

Dizziness

Fibromyalgia

Low Blood Pressure

High Blood Pressure

Arthritis

Skin Problems

Contagious Disease

Persistent Headaches

Diabetes

Foot Issues

Cancer

Skeletal Injuries

Chest Pains

Insomnia

Heart Disease

Consent Form and Signature *

I understand that the massage therapy I am receiving at reishi is for the purpose of stress management, relief of muscle tension, and increasing circulation and energy flow. I understand that the massage therapist does not diagnose illness, disease or other physical or mental issues. The massage therapist does not prescribe medical treatment or pharmaceuticals, nor do they provide any spinal manipulations. Massage therapy is not a substitute for medical evaluations or diagnosis and reishi recommends seeing a medical professional for ailments I might have. We require 4-hour notice during operating hours for any cancellations. If you are unable to come to your appointment, or if you cancel without at least 4 hours notice, we reserve the right to charge 50% of the total of scheduled services.

I Agree