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Sports massage registration & consent
Please fill in the form below with as much information as possible, fields marked in red are required.
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1
Full Name
*
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First Name
Last Name
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2
Phone Number
Area Code
Phone Number
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3
Birth Date
*
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Month
Day
Year
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4
Gender
*
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Please Select
Male
Female
Please Select
Please Select
Male
Female
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5
E-mail
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6
What medications or drugs are you taking?
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7
Do you suffer from any of the following? (Please check all that apply)
*
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Thyroid
Heart
Arthritis
Epilepsy
Asthma
Diabetes
Used Steroids
Breaks and fractures
Oestioporosis
No
Other
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8
If you checked any of the options above or have other medical problems, please detail below:
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9
Patient's Signature
*
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Please type your name below to indicate consent to treatment.
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10
Date
*
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Month
Day
Year
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