Patient Intake & Consent Form
MR Osteopathy & Massage
New Patient
Questionnaire
Full Name
*
First Name
Last Name
Date Of Birth
*
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Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Occupation
How did you hear about us?
*
Emergency Contact
*
First Name
Last Name
Phone Number
*
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Health History
:
Doctor's Name
Address
Phone Number
Please enter a valid phone number.
Current Medications/ Conditions they treat
Surgeries (Please list and date)
Motor Vehicle Accident(s)
YES
NO
Date(s)
Please list any applicable conditions (past and current)
Other Accidents, Traumas or Injuries (Please list and date)
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Health History
:
I hereby request and consent to the performance of osteopathic manual therapy and/or massage tharpy performed by the osteopathic practitioner and registered massage therapist named.
I have had the opportunity to discuss with the practitioner named any questions or concerns that I have regarding my condition and any forms of therapy to be administered. I understand that the results are not guaranteed.
I understand and am informed that, as in all health care, there are some very slight risks to treatment, including but not limited to, muscle aches and soreness following treatment. I do not expect the practitioner to anticipate and explain all risks and complications, and I wish to rely on the practitioner to exercise their judgment and I understand that all procedures are in my best interests.
I have read the above consent. I have also had the opportunity to ask questions about its content, and by signing below, I agree to the above-named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.
Print Name:
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Signature
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