New Patient Intake

Med Massage And Wellness Clinic

Unit 207, 1762 34 Ave, Edmonton, AB, T6T-1Y9, 780-461-5000

CONFIDENTIAL HEALTH HISTORY

An accurate health history is important to ensure that it is safe for you to receive a massage treatment. All information gathered for this treatment is confidential except as required or allowed by law. Written authorization for release of any information.

Name

First Last

Date of Birth

Address*

Street Address Address Line 2 City Province Postal Code

Phone*

Email*

For Women Only:

36 Hours cancellation notice is required or missed appointment fee will be charged.

Reason for Massage Therapy Treatment:

General Health Status:

Excellent
Good
Fair
Poor

Indicate pain and/or stiffness by selecting appropriate option - Indicate numbness and/or tingling with an 'N' or 'I'

a	b	c	d	e

Indicate pain and/or stiffness by selecting appropriate option*

Health History: Please select from the options below for any conditions that you are experiencing or have experienced

To select multiple conditions press CTRL+ your condition on your keyboard if you are using a desktop to fill this form.

Respiratory:*

Cardiovascular:*

Skin:*

Other Conditions:*

Head and Neck:*

Infections:*

Soft tissue / Joint / Nerve*

Consent and Policy Statement

I have read and completed this form and stated all medical conditions that apply to me to the best of my knowledge. I will notify the Massage Therapist of any changes in my health status to ensure my safety for receiving massage.

I understand that Massage Therapist do not diagnose illness, disease, or any physical / or mental disorder; nor do they prescribe medical treatment, pharmaceuticals, or perform chiropractic adjustments. I acknowledge that massage is not substituted for medical examination or diagnosis and that it is recommended I see a Medical Doctor for that service.

If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/strokes can be adjusted to my level of comfort. I will not hold my therapist responsible for any pain or discomfort I experience during or after the session.

I understand that massage is entirely therapeutic and non-sexual in nature.
I understand I must give 36 hours notice for cancellation of appointment that I will be charged the service fee if cancelled on that same day.

Consent*

I agree to the Med Massage and Wellness Clinic policy.

* I have read and completed this form and stated all medical conditions that apply to me to the best of my knowledge. I will notify the Massage Therapist of any changes in my health status to ensure my safety for receiving massage.
* I understand that Massage Therapist do not diagnose illness, disease, or any physical / or mental disorder; nor do they prescribe medical treatment, pharmaceuticals, or perform chiropractic adjustments. I acknowledge that massage is not substitute for medical examination or diagnosis, and that it is recommended I see a Medical Doctor for that service.
* If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/strokes can be adjusted to my level of comfort. I will not hold my therapist responsible for any pain or discomfort I experience during or after the session.
* I understand that massage is entirely therapeutic and non-sexual in nature.
* I understand I must give 36 hours notice for cancellation of appointment that I will be charged the service fee if cancelled on that same day.

Consent*

I hereby waive and release my therapist from any and all liability, past, present, and future relating to massage therapy and bodywork.

Consent*

I hereby declare that the above information provided in this form is true to the best of my knowledge.

A parent or legal guardian must authorize a child younger than 18 years of age to receive massage therapy treatment.

Date of filling the form*

Email

This field is for validation purposes and should be left unchanged.

Contact Info

CONFIDENTIAL HEALTH HISTORY

Med Massage And Wellness Clinic

CONFIDENTIAL HEALTH HISTORY

36 Hours cancellation notice is required or missed appointment fee will be charged.

Health History: Please select from the options below for any conditions that you are experiencing or have experienced

Consent and Policy Statement

Contact Info