Date *
Date
Name *
Name
Phone *
Phone
If yes, how many weeks?
Have you consumed alcohol in the last two hours? *
Check all conditions that you are affected by: *
If yes, please describe.
Consent Form and Signature *
I understand that the massage therapy I am receiving at reishi is for the purpose of stress management, relief of muscle tension, and increasing circulation and energy flow. I understand that the massage therapist does not diagnose illness, disease or other physical or mental issues. The massage therapist does not prescribe medical treatment or pharmaceuticals, nor do they provide any spinal manipulations. Massage therapy is not a substitute for medical evaluations or diagnosis and reishi recommends seeing a medical professional for ailments I might have. We require 4-hour notice during operating hours for any cancellations. If you are unable to come to your appointment, or if you cancel without at least 4 hours notice, we reserve the right to charge 50% of the total of scheduled services.