Physician’s Permission form

Physician's Permission form

Patient Information Information

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:

Special instructions:

Permission Granted by

Physician/Health-Care Provider Name:

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.

Date