New Customer Registration Form

New Customer Registration Form
Customer Details:
Full Name

First NameLast Name
Gender/Pronouns
Birthday

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parking location
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
How did you hear about us?
Please Specify
Occupation
What areas would you like to focus on?
Emergency Contact

First NameLast Name
Emergency Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Do you have a family doctor or nurse practitioner monitoring your health?
Doctors Name
Doctors Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Health History
Please Indicate if you have or been treated for any of the listed conditions

Other
Any injuries, surgeries, implantations
Other comments regarding your health
Ladies, are you pregnant or trying to conceive?
If yes, how many weeks
Medications and/or supplements
Terms & Conditions
** Cambridge/Kitchener/Waterloo patients prices start at $200.00

** All extra fees such as parking will be your responsibility to pay for

**Patients living in apartment buildings will be charged an extra $5.00 for the extra time needed to carry the heavy equipment to you

**If you do not provide clear instructions on how to get to your location, you will be charged an extra $10.00

** A non refundable deposit of $80.00 must be deposited to tanishadouglasrmt@gmail.com in order to solidfy your appointment
I understand the terms and conditions listed above in regards to the deposit and extra fees that will be added to my total.
Signature
Consent to Treatment
Consent to Treatment

The registered massage therapist has asked me questions about my condition/ reason for treatment, and has expressed to me her approach to treament. I feel comfortable that the therapist has explained to me the risks and benefits of the treatment and I approve of the treatment plan provided to me.
Signature
Consent For Acupuncture

The massage therapist has throughly assesd my health, my are of complaint, and goals of treatment and has suggested acupuncture. I understand there is a risk acupuncture can cause bruising, punctured organ, soreness, increase or decrease in blood pressure, and a risk to pregnant women. I also understand the therapist is NOT a licensed acupuncturist and can not treat any conditions other than musculoskeletal related.
Signature
I have requested assessment and/or treatment by Tanisha Douglas the Registered Massage Therapist (RMT) , for treatment of the clinically relevant areas indicated below
Signature
Consent To Pictures and Videos

I give consent for Tanisha Douglas (RMT), to take and post photos and/or videos of me taken during my treatment. I understand my face will not be in any content (unless relevant such as facials), as these pictures and/or videos are for webiste and social media content ONLY! I also acknowledge NONE of my personal information will be posted, or given to any other health care professional ( unless upon request) such as; name, date of birth, address, etc. I understand that if at any point I feel uncomfortable I will advise the therapist.
Signature
***For patients under the age of 18***

I am the legal Parent/Guardian of the patient being treated. On my behalf , I approve of the treatment plan and give my consent to Tanisha Douglas (RMT), to proceed with the treatment(s).
Parent/Guardians Name

First NameLast Name
Signature
Date signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Direct Billing Information

I understand that I am financially responsible for any portion of the fees, deductibles, or denied claims not covered by my insurance provider.
Insurnace Provider/ Company Name
Policy Number/ Plan ID
Certificate/ Member ID
Primary Cardholder Name ( if different from client)
Cardholder Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Should be Empty:

New Customer Registration Form

Health History

Terms & Conditions

Consent to Treatment

Direct Billing Information