Associated Bodywork & Massage Professionals
MEMBER

Practitioner/Clinic Name: Veda King Blanchard/Rooted Arts

 Contact Information: (862)202-6948; rootedarts@gmail.com

Patient Information

Patient Name: _________________________________ Date of Birth: ______________

Permission Granted to

Provider Name: _______________________________

Specialty/Type of Treatment: ________________________

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.