New Client Form

New Client Form
Name*

First NameLast Name
Date of Birth*

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Date
Referred By:*
Email Address *
example@example.com
Mobile Phone # *
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Home Phone #
Work Phone #
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Name *
Emergency Contact Relationship *
Emergency Phone # *
Date Of The Initial Visit *

DayMonthYear
Date
Reason for initial visit*
I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of the effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination, or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status.

I understand that my personal health information will be collected. I understand that all information that I provide will be kept confidential unless required by law. I understand and consent that my medical information may be shared by the various care providers involved in my care and treatment.
Signature*

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Date*

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Date
Signature*

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SUBJECTIVE