Client's Information/Consent CLIENT INFORMATION & CONSENT FORMName*Email address*Phone Number*Birthday*Street AddressStreet Address Line 2City Province/Territory/StateCountryPostal codeEmergency Contract Name*Emergency Contact Phone Number*Please list all allergies/sensitivities. If not applicable, enter "NA".*Please list all accidents, surgeries, or serious hospitalizations and year in which they occurred. If not applicable, enter "NA".*How did you find out about Therapeutic & Relaxation Massage Clinic?The fields in the following section are optional, but help your therapist know more about your goals for your appointment. What are your main complaints? Where is/are the problem(s) located? When did it/they start? How? If no complaints, enter "NA".Phone Number*Optional: I have no complaints that I want addressed during my appointment.Check the boxes the apply to the complaint expressed above:The condition is reoccurring.The condition is getting worse.The condition is persistent, but hasn't progressed to get any worse.The condition is getting better.How often does the condition bother you?Have you noticed a pattern with the symptoms of this condition? (Time of Day/Year, etc.)What makes the condition feel better? (Heat, Cold, Pressure, etc.)What makes it worse? (Heat, Cold, Pressure, etc.)Check the box(es) that describe your pain (if any):Dull/AchesShootingPin PrickTightSqueezingBand SensationExpandingDoes the pain radiate anywhere?Severity of the pain on a scale of 1 to 10 (10=worse pain)Consent for Treatment at Therapeutic and Relaxation Massage Clinic I am hereby requesting massage treatments from contracted massage therapists at Therapeutic and Relaxation Massage Clinic which include relaxation, deep tissue, prenatal, essential oil, hot stone and cupping massage. New complications and concerns, if they do arise, will be discussed with my practitioner, and appropriate action will be taken. I understand that although these are natural and alternative treatments, I am seeking, there may be risks of bruising, pain in treated area, and worsening of symptoms during the healing process. I hereby release Therapeutic and Relaxation Massage Clinic and all practitioners/therapists treating me from all liabilities. I am also aware of the clinic's late cancellation policy of a charge of 50% of the visit cost if I fail to give less than 24 hours notice for cancellation, I will be responsible to pay that charge before I can re-book. Mandatory Field: I accept these terms and conditions. Clean Save Signature Please click the save signature button before submitting. Today's DateSend
