Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Are you taking any medications ? *

YES (If Yes list below)

NO

Are you currently pregnant ?

Yes

No

Do you currently or have you ever had any of the following: (please check)

Asthma

Digestive Disorders

skin condition

Hepatitis

Headaches/Migraines

Herniated/Bulged Disc

Arthritis

Cancer

Nervous Disorders

Heart Condition

Informed Consent *

I understand that the therapist providing my massage therapy service is practicing within their scope of practice as defined by the governing bodies represented in Canada. I consent to assessment and treatment techniques recommended by the therapist and I acknowledge that the therapist is not a doctor. I acknowledge that no assurance or guarantee has been provided to me as to the results of the treatment. I acknowledge that with any treatment there can be risks and those risks have been explained to me and I assume those risks. I have completed my medical history to the best of my ability and have disclosed to the therapist all medical conditions affecting me, I assume the responsibility to keep my therapist updated on my medical conditions. By signing this form, I consent to treatment and intend this consent to cover the treatment discussed with me and such additional treatment as proposed by my therapist. I understand that at any time I may withdraw my consent and treatment will stop.I am aware of the 24-hour cancelation policy, If I fail to give 24-hour notice prior to my appointment, 50% of my service(s) will be charged on my credit card.I agree to be contacted periodically with special offers or services.

I have read and accept Informed Consent