Client Details:
Full Name
*
First Name
Last Name
DOB
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Your Mobile Number
*
Format: (000) 000-0000.
Your E-mail
*
example@example.com
What is your Occupation?
*
Name of Emergency Contact
*
Number of Emergency contact
*
Please enter a valid phone number.
Format: (000) 000-0000.
Reason for appointment :
*
Previous Medical /Injury History :
*
Are you taking any medication ?
*
Yes
No
If You answered yes to the above question please give details:
Do you have any other health conditions not mentioned above your therapist may need to know about i.e pregnancy, Diabetes, Asthma, Heart disease, cancer etc ?
*
Yes
No
If You answered yes to the above question please give details:
Informed Consent Massage/neuromuscular therapy may not be suitable for individuals with some medical conditions or injury scenarios. Your Doctors clearance maybe needed prior to treatment being provided. I fully understand that thorough and honest responses to all question are essential to my safety. I hereby confirm that all the information stated above is accurate to the best of my knowledge and I undertake to inform my therapist of any changes. I further understand that prior to any treatment a physical assessment needs to be carried out which will test posture, range of motion, muscle shortness etc. If at any point during the treatment I am uncomfortable or uneasy with the techniques and/or assessment, or if I experience pain, I understand it is my responsibility to immediately inform therapist so that procedures can be adjusted to my level of comfort or, if necessary, the treatment can be terminated. Signature
*
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