New Client Intake Form

Full Name

First NameLast Name

Date of Birth

Date

Address

Street Address

CityPostal / Zip CodeCountry

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Occupation

Emergency Contact Name

Please enter contact name

Emergency Contact Phone

Please enter a valid phone number.Format: (000) 000-0000.

Referred By

How did you find us?

Have you received Myofascial Release Therapy or similar complementary treatments before?

If yes, please provide details about your previous therapy experience.

Body Area

On a scale of 1 to 10, how would you rate your current pain or discomfort?

What Triggers the Pain?

Is there anything that eases your pain or discomfort?

Are you allergic or sensitive to anything (e.g., lotions, medications, foods)?

In particular Bees / Beeswax or Coconut Oil

Have you had any surgeries?

If yes, please list your surgeries and dates (if known):

Are you currently taking any medications?

If yes, please list your current medications:

Reason for seeking treatment

What are your expectations from this therapy?

I First Name* verify that all information is correct and current to the best of my knowledge. I understand that any information provided is for safety purposes and will be kept strictly confidential, unless I provide written consent. I hereby give my consent to receive treatments and I acknowledge and agree that I am doing so at my own risk. My health and safety with respect to such services are my sole responsibility. My decision to receive services is voluntary, and I know of, understand and assume any and all the risks associated therewith. In exchange for receiving services for myself and on behalf of my heirs, executors, administrators and personal representatives, hereby waive, release, discharge and hold my therapist harmless from any and all liability for any and all injuries, including damages or claims relating to or resulting from my receipt of the services, now or in the future, foreseen or unforeseen.

Please take a moment to read and initial the following information:

If I experience pain or discomfort during the session, I will immediately inform my therapist. I will not hold my therapist responsible for any pain or discomfort I experience before, during or after the session.
I understand that the services offered today are not a substitute for medical care.
I understand that my therapist is not qualified to carry out a medical examination or provide a diagnosis and I agree not to interpret their comments as medical advice.
I affirm that I have notified my therapist of all known medical conditions and injuries.
I agree to inform the therapist of any changes in my health and medical condition. I understand that there shall be no liability on the therapist’s part should I forget to do so.
I understand that treatment is non-sexual in nature.
I understand my medical information and treatment notes may be released to other, third party, health practitioners whom I agree for my therapist to refer me to.
I agree that my therapist will need to disclose my personal information, if required to by law.
By signing this release, I hereby waive and release my therapist from any and all liability, past, present and future relating to this treatment.

Signature

New Client Intake Form

Presentation & History

Client Consent & Waiver