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  • Physician Permission

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    Carole Arms
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    This permission form grants a practitioner or clinic permission to provide massage or bodywork treatment to a specific patient. It notes that the treatment is not expected to harm the patient's progress but provides space to include any considerations like descriptions of the patient's condition, possible medication interactions, or special instructions. The form is to be signed and dated by the patient's physician or health care provider to give their permission for the specified treatment by the named practitioner or clinic.

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    Physician Permission

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    This permission form grants a practitioner or clinic permission to provide massage or bodywork treatment to a specific patient. It notes that the treatment is not expected to harm the patient's progress but provides space to include any considerations like descriptions of the patient's condition, possible medication interactions, or special instructions. The form is to be signed and dated by the patient's physician or health care provider to give their permission for the specified treatment by the named practitioner or clinic.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    16 views1 page

    Physician Permission

    Uploaded by

    Carole Arms
    This permission form grants a practitioner or clinic permission to provide massage or bodywork treatment to a specific patient. It notes that the treatment is not expected to harm the patient's progress but provides space to include any considerations like descriptions of the patient's condition, possible medication interactions, or special instructions. The form is to be signed and dated by the patient's physician or health care provider to give their permission for the specified treatment by the named practitioner or clinic.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    Practitioner/Clinic Name: ____________________ Physician/Health-Care

    Contact Information: ________________________ Providers Permission

    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 patients 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.

    MEMBER
    Associated Bodywork & Massage Professionals

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