Totoe Medical Services Massage Therapy
Appointment Request and Consent Form
Client Information
Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
Format: (000) 000-0000.
GPS Address
Emergency Contact Details
In case of emergency, we will contact the person below:
Emergency Contact Name
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Health Data
Do you have any allergies?
If yes, please specify on the field above.
Are you on blood thinners?
If yes, please specify on the field above.
Do you have any current injuries?
If yes, please specify on the field above.
Please tell us about any relevant medical conditions pertinent to your comes.
If yes, please specify on the field above.
Location of painful areas
Consent and Waiver
I, undersigned, agree with the following statements:
I authorize Totoe Medical Services to provide massage services in my home
I authorize the use of lotion, oil, and ointments to my body.
I acknowledge that I have consulted a physician before undergoing this massage treatment. I understand that I should consult my doctor before the procedure.
I understand that this is an alternative treatment and if there are any medical concerns, I need to talk to my physician.
I acknowledge that this massage therapy has no sexual intent and touching the therapist is strictly prohibited.
I release Totoe Medical Services of any responsibility in case of an accident, illness, or injury.
I acknowledge that all information I provided in this form is true and accurate.
Preferred time and date
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Alternate preferred date and time
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Our massages are 345 Ghc for a home massage with tax. We will send an invoice when your appointment is confirmed. Please sign below agreeing to your responsibility for the cost. We accepts tips as well if our therapists do a great job.
Date Signed
-
Month
-
Day
Year
Date
Submit
Submit
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