Massage client release form
I herby give my permission to release any medical information to _________________________________________________________________________________________________
Address _________________________________________________________________________________________
Phone ____________________________________________ Cell __________________________________________
For a massage therapy session
Dr‘s Name _______________________________________________________________________________________
Address ________________________________________________________________________________________
Phone number _________________________________________________________________
Dr’s Signature _________________________________________________________________Date ______________
Therapist Signature ____________________________________________________________ Date _____________
Accept this release as authorization to discuss any medical condition with the named professional and to offer them medical files if needed, as well as any treatments applies will be tolerated.
Patients Name ___________________________________________________________________________________
Social security # __________________________________________________________________________________
Patient signature __________________________________________________________________________________
Return to: Week one or Syllabus
Trinity School of Therapeutic Massage
