General Agreement and ConsentI, _______________________________________________, understand that the

massage/energy work given to me by__Cathy L. Berk, LMT______________is for the purpose of general health and wellness, relaxation, improved circulation, pain management, and other effects supported by experience and research. Massage therapy is performed here within the scope of practice of massage therapists in Indiana.

I understand massage therapists do not diagnosis medical conditions, prescribe medical treatments or medications, nor perform spinal manipulation or chiropractic adjustments.

I understand massage therapy and/or energy work is not a substitute for a medical provider. It is recommended that I seek medical attention for any illness, injury, or disorder.

I understand massage therapy and/or energy work can be a valuable complement to my health care provided by my medical physician(s), chiropractic physician, naturopathic physician, other complementary care providers, psychiatrists and psychologists. I agree to inform my massage therapist of any and all medical treatments I am receiving with the understanding it may impact the massage therapy and/or energy work I receive.

I have stated all of my known medical conditions, treatments and medications, including over-the-counter products and will inform my massage therapist when there are any changes.

My signature below confirms my agreement to the general policies, privacy policy and consent statements above.

Alive Again massage therapyFor you. About you.

Phone: 219.861.7628 email: cathylberk@yahoo.com

Name___________________________________________Date_________