Event “Health Intake & Consent to Treatment” Formfor Hannah Listle, LMT MA93925 Name * First Name Last Name Phone * (###) ### #### Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Have you had a massage before? * Yes No, this is my first massage Do any of the following apply? * History of blood clots, stroke, heart attack Pacemaker Previous broken bones and/or joint replacement Previous injured/torn muscle, tendon, and/or ligament Pregnant Wear contacts, hearing aids, insulin pump Do you consent to receive a massage? * Yes No Thank you!
