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Medical Clearance For Massage Treatment Form

Client Details


Birthday
Day
Month
Year

Medical Information:

please list any medical conditions, recent surgery, or medicatioins

Clearance Decision (choose one)

Single choice
Fit for massage
Fit with restriction
Not suitable for massage

If restrictions apply please specific


Disclaimer:


massage treatment is not a substitute for medical care. Results may vary and no guarantee is given.


Role:
Date
Day
Month
Year
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