A TO ZEN THERAPIES: New client form

Your details *

First Name Last Name

E-mail *

HOW DID YOU HEAR ABOUT US? *

Google search Light centre Treatwell Classpass Work of mouth

DOES ANY OF THESE CONDITIONS APPLY TO YOU? *

Please give details if you have selected any of the above or if you suffer from ANY OTHER RELEVANT/SERIOUS CONDITION that it's not mentioned:

HOW CAN WE HELP? IS THERE ANY SPECIFIC REASON FOR YOUR TREATMENT (i.e sprain, neck pain, relax, etc..)

CAN WE CONTACT YOU OCCASIONALLY BY EMAIL? (We usually send a monthly newsletter with our latest offers and healthy tips) *

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PLEASE READ CAREFULLY

1) I, the undersigned, declare that the information I have given is true to the best of my knowledge and I have no withheld any information concerning my health. I understand there is a possibility I may develop some minor reactions as my body adjusts to treatment.

2) I understand, and I am informed that in the practice of Massage Therapy there are some slight risks to treatment, including some minor reactions such as muscle and joint soreness, as the body adjusts to treatment. but also muscle strains, joint sprains, fractures, disc injuries, nerve injuries, stroke and stroke-like episodes and possible worsening of underlying conditions. I understand that results are not guaranteed, I do not expect Monica Pineider, the massage therapist, to be able to anticipate and explain all risks and complications, and I wish to rely on the therapist to exercise judgment during the course of the treatment, which she feels at the time, based upon the facts then known, is in my best interests.

THE INFORMATION PROVIDED ON THIS FORM WILL BE TREATED WITH THE STRICTEST CONFIDENCE AND SAFETY

If you agree with all the above, please sign below. *

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