Located in Arlington, Texas

Located in Arlington, Tx

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tbtmassage.com

Physician/Health-Care

Provider’s Permission


Practitioner/Clinic Name:                                                             

Contact Information:                                                                     

 

Patient Information

Patient Name:                                                                                                   Date of Birth:                                                                    

 

Permission Granted to

Provider Name: True Balance Therapeutic Massage                          Specialty/Type of Treatment:                                    

                                                                                               

(i.e., Swedish, Deep Tissue, Lymphatic, Sports Massage, Trigger Point, Senior Massage, Pre-Natal Massage, etc…)

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:                                                                                                                                                  

Phone:                                                                 Fax:                                                        Email:                                                                   

 

Signature:                                                                                                                           Date:                                                                    

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.