New Client Form

New Client Form
Name

First NameLast Name
Date of Birth

DayMonthYear
Date
Referred By:
Email Address
example@example.com
Mobile Phone #
Please enter a valid phone number.Format: (000) 000-0000.
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
Date

DayMonthYear
Date
Signature
File Upload

Cancelof

SUBJECTIVE