Rejenbody Client Intake and Consent Form

Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date*

MonthDayYear
Phone Number*
This is my:*
E-mail*
Occupation
Emergency Contact*
Relation to Client*
Phone Number*
General Information
Height*
Weight*
1. What would you like to gain from your sessions?*
2. Describe the symptoms you are experiencing. Is it chronic or recent?*
3. Is there anything that you do that creates, increases or decreases pain? *
4. List all related treatments received for this injury.
5. Have you ever been in an accident (automobile, work, falls, etc.) ?*
6. Please list any surgical procedures you have had along with the year.*
7. What are the physical duties required of your occupation?*
8. What activities/hobbies do you enjoy?*
9. Please list exercise (including frequency).*
10. Are you currently under the care of any other healthcare professional?*
11. List any medications you are currently taking and conditions they are for.*
12. Please check any that apply to you:*

Allergies, SensitivitesHeadaches, MigrainesHigh/Low Blood PressureTMJ problemsOsteoporosisNumbnessBlood ClotsStrokeHeart/Circulatory problemsCancer, TumorsFibromyalgiaArthritisSkin ConditionDiabetesNoneOther
Informed Consent

I understand that the sessions I will be receiving is:
- for therapeutic purposes and is non-sexual
- to assist in balancing and aligning the physical body through direct manipulation, appropriate contact and movement education.
I understand that the practitioner makes no warranties or guarantees as to the results of the process and give consent for the practitioner to apply appropriate physical contact to my body. I understand that if I experience any unusual discomfort and/or pain during my session, it is my responsibility to actively communicate this to the practitioner so that he/she can adjust the pressure or technique being used, or if necessary, end the session. I may also, at any time, request to terminate the session.

I understand that the practitioner does not diagnose illness, disease, or any further physical or mental disorders and the session should not be a substitute for medical treatment or diagnoses from a medical professional when such attention is required.

I acknowledge that the information I have provided on this form is correct and current to the best of my knowledge, and that I have provided a truthful and accurate medical history. I understand that it is my responsibility to inform the practitioner of any changes to this information.
Privacy Policy

All written records and sessions are kept strictly confidential and will not be shared with any outside establishment, individuals, organizations, or medical facilities without explicit written consent from the client (you) or the client’s legal guardian, unless legally required by local, state, or federal subpoena, summons, or other court order.

I acknowledge that I understand my rights as the client receiving services. I am aware that I can request an additional copy of this document at any time.
Cancellation Policy (as of Nov 16, 2021)

Should I need to reschedule my appointment, I acknowledge that a minimum 24-hour cancellation notice by phone prior to my scheduled appointment is required. I agree to be billed
- $80 if I reschedule or cancel within 2 to 24 hours of my scheduled session time, or
- for the full cost of a session if I do not provide notification 2 hours prior to the agreed start time of the session or do not show for my scheduled session.
By my electronic signature below, I acknowledge that I have read and agree to:*

The Informed ConsentThe Cancellation PolicyThe Privacy Policy
Today's Date*
Signature*

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Jennifer Soon s (302) 494-8222 s rolf.soon@gmail.com s www.rejenbody.com
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