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Information you provide is HIPAA compliant

Before your first appointment you can save time & money by completing this form as honestly as possible.

Name	First    thank you
	Last   thank you
Address	thank you
Phone	Fax      thank you
Email	thank you
Occupation	thank you
Date of Birth	thank you
acute or chronic conditions	include anything you consider relevant in the box provided	thank you
	Fever Asthma cancer History of seizures Recent Heart Attack Renal insufficiency Epilepsy Post traumatic stress Communicable skin conditions Open wounds Trauma of any kind Acute inflammation or pain Conjestive heart failure Phlebitis or deep vain thrombosis Severe vascular disorder
List Rx meds & OTC supplements		Primary care physician contact info  thank you
any other info	thank you
Initial	"I confirm that I understand the LMT is not licensed to diagnose any disease state. I, the client, assume full responsibility for my health status. I choose of my own free will to have massage therapy. I, the client, agree to inform the therapist if the status of my health changes"   thank you