Therapeutic Massage Counsel - New Client Registration

Therapeutic Massage Counsel
222 Fairview Drive
Suite 203
Brantford., ON
N3R 2W9 CA

New Client Registration

An accurate client health history is important to ensure that it is safe for you to receive a massage treatment. If your health status changes in the future, please let us know. All information gathered for this treatment is confidential except as required or allowed by law or to faciliate diagnosis (assessment) or treatment.

Please complete ALL required (*) fields.

Personal Information

* First Name
* Last Name
* Birth Date

* Gender
* Dominate Hand

* Address
* City
* Country
* Province/State
* Postal / Zip
* Home Phone
Mobile Phone

* Emergency Contact
* Emergency Phone

* Occupation
Work Phone
Ext.

* Family Doctor
Other Medical Practitioner
* Family Doctor Phone

* Email Address
* New Account Password

* How did you hear about our Clinic?

* Have you seen a
Massage Therapist before?
If yes, how often?

Date of Last Massage

Session Details

* What is your main reason for visiting the clinic today?
* What are your current medications?

Surgeries & Accidents

Surgery Details
Accident Details
Date
Date

Symptoms & Conditions

Musculo-Skeletal
Infectious Diseases
Skin Conditions
Circulatory & Cardiovascular
Respiratory
Digestive
Reproductive
Nervous System
Other

Other Medical Conditions
Comments of Special Note

When you are finished, please continue to the Registration Agreement tab below and sign to complete the form.

Registration Agreement

  1. I understand I will be receiving specific procedures for Massage Therapy to treat my presented condition(s). Therefore I give consent for any Registered Massage Therapist within this facility to perform this agreed upon treatment.

  2. I understand that my personal information is protected and will not be given to anyone outside clinic use, without my written consent, and will only be used for Massage Therapy purposes.

  3. I also understand I must give 24 hours notice of any appointment change or cancellation otherwise I will be charged the full appointment price.

* Type your name for your signature
Date Signed:
December 19th, 2018