Schedule Now: 817-228-5683

(Text & Afterhours number: 682-365-1903)


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.