New Client Health Questionnaire & Consent Form

Name*

First NameLast Name

Date of Birth*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Subscribe to Newsletter?

YesNo

Please upload a scan or photo of your Photo Identification *

Emergency Contact Name*

Relationship to Client

Emergency Contact Phone *

How did you find out about Refresh Bodywork?

If referred please specify:

If other please specify:

The following information is used to help plan safe and effective treatments sessions.

How would you rate the current state of your health?

ExcellentGoodFairPoor

How would you rate your stress level?

HighModerateLow

Are you currently under a doctor’s care? If yes, please explain.

Are you pregnant? If yes, how many weeks gestation?

Are you taking any medications? If yes, please list.

Are you currently undergoing any other therapies?

Do you have any communicable diseases? If so please explain.

Do you have any of the following health conditions?

If you checked off any of the above health conditions please explain.

You Need to Know That:

I am not a doctor.
I do not practice medicine.
I do not diagnose.
I do not prescribe or adjust medication.
The treatments offered by Refresh Bodywork are not a substitute for medical treatment, but are complimentary to most types of therapy.

You agree to the following:

If i have been diagnosed by a licensed health professional as having any disease, injury or other physical or mental condition, I understand that I should inform the person who made this diagnosis about the treatment(s) I am receiving.
If i have any communicable condition or condition that may contaminate the therapist and equipment, I may be refused service until such time as the condition is certified as cleared.
I understand that any treatment received from. Refresh Bodywork should not be construed as a substitute for medical treatment and that I should see a medical professional for any mental or physical ailment.
I fully understand that the therapist is not a doctor or registered massage therapist, and does not portray herself to be.
I agree to keep the therapist updated as to any changes in my medical profile prior to any future sessions and understand that there shall be no liability on the therapist's part or on the part of Refresh Bodywork, or it's affiliates should I fail to do so.
I understand that if I have any pets, they must be kept out of the treatment space during the duration of the treatment.
I understand that full payment is due at the time of service, unless paid for previously.
I understand that I am liable for payment of all scheduled appointments.
The therapist reserves the right to refuse service to anyone for any reason

By signing this form, I certify that the above information is correct to the best od my knowledge. I give my consent to receive treatments from Refresh Bodywork. I understand that I may discontinue a treatment at anytime for any reason, and if I feel uncomfortable I should tell the therapist. I acknowledge that I have read and understand all parts of this consent/intake form, and that I have had the opportunity to ask any questions with regard to any services or therapies offered.

All client information is confidential.

Date*

Date

Name of parent or guardian if 18 or younger

Signature (parent or guardian signature if 18 or younger)*