Health Form & Informed Consent

Please take a moment to fill and submit this form before your first massage & bodywork appointment. This information is important for us to gather in order to safely treat you. It is privacy protected and will not be given out under any circumstance. If you have any questions, please contact Salubria Wellness.

Below is a list of some normal reactions to massage & bodywork therapy:

Needing to change position or move during the session.
Emotional release, expression, & memory recall.
A change in breathing pattern, yawning & sighing.
Digestive activity & releasing gas.

Name: *

Home phone: *

Cell phone:

Street address: *

City: *

State: *

Occupation:

Date of birth: *

Emergency contact: *

Phone number: *

How did you hear about us?:

Referred by:

Email address: *

Have you received professional massage?:

What are you goals for this therapy session?:

Other goals:

List excercise activities and frequency:

Are you currently under the care of a health care practitioner?:

If yes, please specify purpose:

Additional client remarks / comments:

Any information you'd like us to know before we meet with you.

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