Name
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First Name
Last Name
Email
*
Phone
*
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Gender
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Male
Female
Date of Birth
*
MM
DD
YYYY
Occupation
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Family Doctor
How did you hear about us?
Please let us know your primary concern and reason for seeking treatment:
Have you ever had a massage before?
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What amount of pressure do you prefer in a massage?
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What is your height?
*
Please choose the option below that best suits your preference during massage:
*
Have you been in a Motor Vehicle Accident?
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Health Information
Areas of Broken Skin?
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History of joint replacement surgery?
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Recent injuries or medical procedures in the last 2 years?
*
Please describe any other injuries or health conditions:
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Please list any allergies you have(oils, lotions and other, or N/A)
*
Please list any medication you are on and the reason for taking them(or N/A):
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Please list all hobbies, sports, activities that you participate in regularly(Ex: hockey, yoga, knitting, running)
*
Reproductive Health
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Other Concerns
Quality of Sleep
*
Level of Fitness
*
Accuracy of information
*
I confirm that the above information is accurate and true to my knowledge. I understand that the client/therapist relationship will be help with complete confidence and any and all information I provide will only be shared upon my written consent. I hereby release the practitioners at Tetelestai Wholeness & Massage, (Candace Scott), from any and all liability should any problems arise from the treatments I receive due to any incorrect information I have given, or any information requested in this health history that I withheld.
Privacy and Sharing of Information
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I authorize the clinic and it's associated health professionals to collect my personal information as documented above. I also understand that my personal and medical information is confidential and will only be disclosed with third parties with my permission.
Cancellation & Missed Appointment Policy
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Your appointment time is reserved just for you. A late cancellation or missed visit leaves a hole in the therapist' day that could have been filled by another patient. As such we require 24 hour notice for any cancellations or changes to your appointment. Patients who provide less than 24 hour notice, or miss their appointment, will be charged a fee of 50% of the treatment cost.
Payment of this fee will be the responsibility of the client directly and not of the automobile insurance or extended health benefit provider.
Date Signed
*
MM
DD
YYYY
