Medical Information Form Please complete this form before your appointment. Your email is required. Appointment Date Time Location Therapist Duration Patient First name Last name Email * Phone Date of birth Occupation Alternate phone Full name (auto) Emergency contact Name Phone Relationship Medical Medications Allergies Recent injuries / surgeries Chronic pain areas Health conditions (check all that apply) High blood pressure Heart condition Diabetes Pregnant Recent surgery Asthma Other Preferred pressure Light Medium Firm Preferred medium Oil Lotion None Areas to avoid No areas to avoid Consent I confirm the information provided is accurate and I consent to treatment. Your submission is securely stored in your patient record folder. Submit medical form Policies Appointments
