Consultation Form
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1
2Consultation Form
Name:
Phone:
Please indicate below if you have any health conditions of
which your practitioner should be aware:
Do you have any movement restriction to be respected?
YES
NO
If you checked yes above please describe:
Please cirles your areas of tension on the drawing
Date:
/
/
Signature:
DISCLAIMER: The purpose of massage is for relaxation and not meant to diagnose or treat any illness, disease or any other physical
or mental disorder, injury or condition. If you have a specific medical condition or symptom, receiving or performing massage may be
contraindicated or require modification. A referral from your primary care provider may be requested prior to receiving and/or performing
massage. Lotus Palm will not be held liable for any injury or similar condition that arises from the application of massage.
L o t u s P a l m C e n t r e • 5 2 4 4 S t U r b a i n , M o n t r e a l , Q C , H 2 T 2 W 9 , C a n a d a • ( 5 1 4 ) 2 7 0 5 7 1 3 • w w w. L o t u s P a l m . c o m
OCT 2009
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