Page 2 - Client Info Form
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Client Information Form (cont.)  Page 2 of 2

Please clearly mark the body chart below with a highlighter any areas of pain, discomfort or tension.

Please take a moment to carefully read the following information and sign where indicated.

I understand myofascial release/bodywork should not be construed as a substitute for medical examination, diagnosis, or
treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical
ailment that I am aware. I further understand that massage/bodywork practitioners do not diagnose physical or mental
illness, and that nothing said in the course of the session given should be construed as such. Because myofascial
release/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known
medical conditions, and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my
medical profile and understand that there shall be no liability on the practitioner’s part should I forget to do so. It is also
understood that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of
the session, and I will be liable for payment of the scheduled appointment. I understand I will be CHARGED FOR
APPOINTMENTS I CANCEL OR MISS WITHOUT 24 HOURS PRIOR NOTICE of my scheduled myofascial
release/bodywork session. I also understand if I arrive late, I will receive the remainder of my time but will be liable for
payment in full.

Client Signature:_____________________________________________________________Date:_________/_________/_________

Practitioner Signature:________________________________________________________Date:_________/_________/_________
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