Having acknowledged the health questionnaire, I certify that all of the information given to the certified massage therapist with the Fédération québécoise des massothérapeutes (FQM) is true and complete. I hereby authorize the certified massage therapist to share this information with the FQM representative duly authorized to conduct a professional inspection related to the performance of the certified massage therapist’s professional’s activities, as this information is necessary to the exercise of the FQM’s responsibilities.

If uncomfortable, I am aware the massage session can be terminated at anytime–or that I can require clarifications from the massage therapist–regardless of the area of the body being massaged.