Client Information Form — BluehandBodywork

Date

YYYY

Name

First Name

Last Name

Gender

Occupation

Referred by

Mobile Phone

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

Physical Activities

*Other Medical Concerns

Medical Providers Used (Physician, Chiropractor, Acupuncturist, Homeopath

Medications

Years Receiving Bodywork

Styles of Work

Problem Areas

Massage Likes

Massage Dislikes

Statement of Understanding

1. Massage Therapy involves neither diagnosis nor treatment of any medical condition and is not a substitute for medical care. 2. Draping will be used at all times. 3. My genital area will not be exposed or massaged at any time. 4. My breasts will not be exposed or massaged unless I give written consent before each session. 5. I may itemize any areas of my body which I wish to be avoided and these will be avoided. 6. At any time I feel uncomfortable for any reason I may request that the session be ended and the session will be ended. *Areas you would like me to avoid

Signature

Breast Massage Consent

In the State of Texas, massage of female breast tissue is permitted under the law only if the client gives explicit consent for the practice prior to each massage session during which breast massage is performed. If you wish to give consent to have your breasts being undraped and massaged please write the words "I give consent for breast massage" in the line below, then sign your name and enter the date. If you change your mind during your massage and no longer wish to give this consent, please ask the therapist to stop the practice and it will be stopped immediately.