Name *

First Name

Last Name

Date *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Are you pregnant? *

Yes

No

NA

Are you right or left handed? *

Right

Left

Please check all that apply:

Blood Clots (thrombophlebitis)

Heart Disease

Arthritis

Hypermobility in Joints (easily dislocate)

Degenerative discs

History of physical or sexual abuse

Cancer (what type and in what area?)

Please read and check the box to confirm that you have read and agree to the terms: *

Your appointment time is reserved especially for you. If you find it necessary to re-schedule an appointment, a minimum of 24 hours notice is required; otherwise it will be necessary to charge you for the session time. Thank you for your cooperation and understanding. I am a Licensed Massage Therapist in the states of New York and Massachusetts as well as a Certified Trager® Practitioner and therefore comply with the ethical standards of these associations. I do not prescribe, diagnose or treat disease, nor is our work together a substitute for medical treatment or advice of a licensed physician. If you are currently under the care of a mental health practitioner, I highly recommend that you inform them of our work together. Thank you.

I agree

Covid-19 Informed Consent/Waiver *

I understand that close contact with people increases the risk of infection from COVID-19. By signing this form, I acknowledge that I am aware of the risks involved and give consent to receive bodywork from Meg Agnew. I agree to inform Meg if I have had close contact with someone diagnosed with Covid- or have experienced any of the following symptoms in the last 14 days: • Cough • Shortness of breath or difficulty breathing • Fever • Repeated shaking with chills • Headache • Loss of taste or smell • Muscle pain • Sore throat

I agree