client’s information – massage clinic

Name*

Email address*

Birthday*

Street Address

Street Address Line 2

City

City Province

Postal code

Country

Phone*

Occupation

Emergency Contact

How did you find out about our services?

What are your main complaints?/ Problem locations/When did it start?/ How?

Details

Have you had this condition before?

Is it getting worse?

Coming and going

Getting better

How often does it bother you?

Is there a pattern? (time of day/year, etc.)

What makes it better?(Heat, Cold, Pressure, etc.)

What makes it worse?(Heat, Cold, Pressure, etc.)

Does the pain radiate anywhere?

Severity of pain out of 10 (10=worste pain)

Please list all allergies/sensitivities

Please list all accidents, surgeries or hospitalization and year they occured

Consent for Treatment with 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.

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I accept terms & conditions

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Client's Information/Consent

Consent for Treatment with Therapeutic and Relaxation Massage Clinic