Practitioner/Clinic Name: ____________________ Physician/Health-Care
Contact Information: ________________________
Patient Name: _________________________________ Date of Birth: ______________
Permission Granted to
Provider Name: _______________________________ Specialty/Type of Treatment: ________________________
Reason for Permission
There is no reason to believe that massage or bodywork treatments will harm this patient’s progress. However, please note
the following considerations:
Description of condition:
Possible interactions with medications:
Permission Granted by
Physician/Health-Care Provider Name: ___________________________________________________________________
Phone: ________________________ Fax: ________________________ Email: __________________________
Signature: ___________________________________ Date: __________________
Please note: Should you notice anything unusual or significant during treatment, please notify this office immediately.
Otherwise, any update at the conclusion of care would be appreciated.