Doctor’s Consent Form (Download this form as a pdf file here)

Dear Sir/Madam,

Your patient _____________________________ would like receive massage therapy/ bodywork from me.  In going over their medical history there were some concerns that _________________________ (list condition) may be contraindicated for bodywork.

In order to support this client to best of my ability I am asking them for a note from you that clarifies if there are any specific concerns/strokes/modalities this client should not partake of.  Conversely, if there is anything that would be particularly beneficial, would you also list it in your note.

Please write the note be on your letterhead so that I have all pertinent information for future reference.  Please note if you are willing to be contacted for further clarification.

Client Confidentiality Release:

I ________________________________ (Name) authorize my care provider to discuss my condition and release information specific to the scope of care to Sabrina Roberson of Moon Cycle Arts.

Client Name: ______________________________________________________________

Client Signature: ____________________________________________________ Date: ____________

Instructions:

Print out two copies of this form.  Take one to your doctor.  Ask them to write you a note clearing you for treatment and attach the copy of this form to the doctors note that you submit to Sabrina Roberson of Moon Cycle Arts prior to your session.  This must be done at least 24 hours prior to your scheduled session.