Medical Referral

Please note that this is a medical referral template for those seeking treatment with Jessica Belanger, LMT only. 

If you're in need  of a referral for massage therapy I have conveniently added this template to the website so you may print off and bring with you to your medical appointment. If your medical provider agrees that massage is needed for your condition they will fill out this form, fax it over to me and I will contact you once received to book an appointment. 


If you're a medical provider please feel free to download and save this PDF for use when you need a referral source for massage therapy.