Massage Therapy Questionnaire

  • General Information

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Health History

  • Please check all that apply.
  • Please take a moment to carefully read the following information. If you have a specific medical condition or specific symptoms, massage/bodywork may be contraindicated. A referral from your primary care physician may be required prior to service being provided.

  • Consent to treat a Minor: My electronic signature authorizes J.Con Salon and Spa's practitioner to administer massage, bodywork or somatic therapy techniques to my child or dependent as they deem necessary.
  • This field is for validation purposes and should be left unchanged.