Health History Form

If you are a new client to Blackbird Wellness VT, we please ask that you fill out this form prior to your first treatment.  You may also print this form and hand deliver at time of appointment.

Name *
Name
Name and phone
MM-DD-YYYY
Name and phone
If yes, please list
Sleep Habits
Please select one that best describes
Massage can be contraindicated for some medical conditions, please always consult with your primary care physician prior to treatments if you are unsure.
By signing below you are confirming the information you recorded is best to your knowledge, and that you have consulted with your physician to be cleared if you have any medical conditions or issues that may be contraindicated for massage.
Date
Date