Keep In Touch-Initial
Keep In Touch Therapeutics, LLC INITIAL CONFIDENTIAL CLIENT INFORMATION FORM
Name______Birthdate______
Phone (best contact)______email______
What is the main reason for your visit today? ______
List any allergies: ______
Do you have any ongoing/chronic conditions?______If yes, please explain: ______
Have you ever had any serious illness, operations, chronic infections, traumatic accidents, or recent surgeries?_______
Do you wear contact lenses? ______Are you pregnant? ______
Are you under the care of a health care practitioner? If so, please explain: ____________
Are you currently taking any medications?______If so, please list:______
______
Have you ever experienced a professional massage or bodywork session?_____If yes, when?______
If you have tension or soreness in specific areas, please specify area(s): ______
Any other information you believe I should know about prior to beginning your massage and bodywork session?______
PLEASE TAKE A MOMENT TO CAREFULLY READ THE FOLLOWING INFORMATION.
I UNDERSTAND THAT:
-THE MASSAGE/BODYWORK I RECEIVE IS PROVIDED FOR THE BASIC PURPOSE OF RELAXATION AND RELIEF OF MUSCULAR TENSION.
-I PARTICIPATE IN THIS SESSION VOLUNTARILY. IF I EXPERIENCE PAIN OR DISCOMFORT DURING THIS SESSION, I WILL IMMEDIATELY INFORM THE PRACTITIONER SO THAT THE PRESSURE AND/OR STROKES MAY BE ADJUSTED TO MY LEVEL OF COMFORT.
-MASSAGE OR BODYWORK SHOULD NOT BE CONSTRUED AS A SUBSTITUTE FOR MEDICAL EXAMINATION, DIAGNOSIS, OR TREATMENT AND THAT I SHOULD SEE A PROFESSIONAL MEDICAL PRACTITIONER IF NEEDED.
-I UNDERSTAND THAT MASSAGE/BODYWORK PRACTITIONERS ARE NOT QUALIFIED TO PERFORM SPINAL OR SKELETAL ADJUSTMENT, DIAGNOSE, PRESCRIBE OR TREAT ANY PHYSICAL OR MENTAL ILLNESS, AND THAT NOTHING SAID IN THE COURSE OF THE SESSION SHOULD BE CONSTRUED AS SUCH.
-I AFFIRM THAT I HAVE STATED ALL MY KNOWN MEDICAL CONDITIONS, AND ANSWERED ALL QUESTIONS HONESTLY.
-I UNDERSTAND THAT ANY ILLICIT OR SEXUALLY SUGGESTIVE REMARKS OR ADVANCES MADE BY ME WILL RESULT IN IMMEDIATE TERMINATION OF THE SESSION, AND I WILL BE LIABLE FOR PAYMENT OF THE SCHEDULED APPOINTMENT.
-I RELEASE Keep In Touch Therapeutics, LLC & THE MASSAGE THERAPIST FROM ALL LIABILITY ASSOCIATED WITH THIS MASSAGE SESSION.
Client Signature______Date______
Practitioner Signature______Date______
Consent to treatment of a minor: by my signature below, I hereby authorize______(Practitioner’s name) to administer massage, bodywork, or somatic therapy techniques to my child, ______.
Signature of parent/guardian______Date______