Who is your Medical Dr?: blanks *Address: Phone # ___-___-____
For WomenPregnant?: Yes No Due Date: Date Other Gynecological Conditions:
Injury: Date: month & year Injury: Date: month & yearInjury: Date: month & yearInjury: Date: month & year
Surgery: Date: month & year Surgery: Date: year & month Surgery: Date: year & month Surgery: Date: year & month
Do you have internal pins or wires, artificial joints or special equipment? .Yes No Where?
Medication: Condition it treats: Medication: Condition it treats: Medication: Condition it treats: Medication: Condition it treats: Medication: Condition it treats:
• Massage therapy includes the assessment and treatment of soft tissues and joints of the body.• Massage therapy may promote increased circulation, decreased muscle tension, reduced stress and anxiety, improved sleep, and relaxation throughout the entire body, and also other benefits.• Massage therapy may result in dizziness/light-headedness while getting off the table after your massage, and tenderness in the areas treated. If you are uncertain about how you feel after massage, let your RMT know.• Risks for receiving Massage Therapy are determined after your RMT looks over your health history form. Steps to minimize possible risks will be taken, or you will be referred to another health care professional in the case that this is not possible.• The comfort of each client is respected, thus: privacy for undressing/dressing will be given; clothing may be removed or kept on according to your comfort level; only the areas of your body being treated will be visible, all other areas will remain covered during your treatment.• If at any point you wish for your massage treatment to be modified (more or less pressure, change of technique) or stopped altogether, you have every right to request what you need. Open communication with your RMT is important.• Promptness is required for appointment times. In the event of lateness, the massage may be cut short. Fees will be paid for the full appointment cost. Appointments missed without any notification will incur the full cost of your appointment. Cancelled appointments with less than 24 business hours notice will incur 50% of the appointment cost.• Payment is accepted at the time of treatment. Receipts will be issued.