Consent Form
Client Information
Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Details
In case of emergency, we will contact the person below:
Emergency Contact Name
First Name
Last Name
Phone Number
Relationship
Health Data
Do you have any allergies? (Please include if you have allergies to any specific herbs)
If yes, please specify on the field above.
Are you currently taking any medications?
If yes, please specify on the field above.
Please describe what are you complaining about.
If yes, please specify on the field above.
Have you been recently hospitalized due to this condition? Any other reasons?
If yes, please specify on the field above.
Do you have any current or past injuries?
If yes, please specify on the field above.
Current medical conditions like Asthma, Diabetes, Heart problems, Kidney problems, epilepsy, scoliosis, communicable disease, etc.? Any family history on these conditions, please specify.
If yes, please specify on the field above.
Location of painful areas
Consent and Waiver
I, undersigned, agree with the following statements:
I authorize Mr. Elijah Bone to perform the treatment or necessary procedure for me.
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 consult my physician.
I acknowledge that this massage therapy has no sexual intent and touching the therapist is strictly prohibited. I understand that such techniques as physical touch, applied pressure, stretching will be used on my body and head.
I release Mr. Elijah Bone for any responsibility in case of an accident, illness, or injury.
I am signing as custodian (legal parent, medical power of attorney) for: (Name and age of the person receiving treatment). I presented a valid document. _______________________________________________________________________________
I agree with terms of service published on the website.
Signature of the Client
Date Signed
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: