Totally Refreshed Steam, Spa and Salon

RMT


Confidential Client History & Consent Form

   

     

 

Gender

 


General Info

Have you had a massage before?

Are you receiving treatment from any other health care professional?


   

   


Indicate Conditions Currently or Recently Experienced

Infectious Conditions (present today)

Skin Conditions (non-contagious)


Indicate Conditions Currently or Recently Experienced (continued)

Please inform your therapist if you are currently experiencing a “flare-up” of any infectious condition.

Cardiovascular

Digestive

Head & Neck

Respiratory

Muscle | Joint | Bone


Women

Has your doctor prescribed having a massage?


Other Conditions


Wavier

I understand that the massage that I receive is provided for the basic purpose of relaxation, stress reduction and relief of muscular tension. I further understand that massage should not be construed as a substitute for the medical examination, diagnosis or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any physical ailment that I am aware of. I understand that massage therapists are not qualified to perform skeletal adjustments, diagnose and/or prescribe, and that nothing said in the course of the session should be constructed as such. Because massage is contradicted under certain conditions, I affirm that I have stated all my known medical conditions and answered all the questions honestly. I agree to keep the therapists updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I do so. It is understood 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 for the full scheduled appointment. Please note we have a minimum 2-hour cancellation policy for all appointments, if the 2 hours is not met and you need to cancel, you are responsible for 100% of the missed appointments. All missed appointments must be paid in full before future services may be rendered. All patrons must be over the age of 18 years OR have all forms signed by a parent or legal guardian.

 

 

 

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Signature Certificate
Document name: RMT
Unique Document ID: 3f4fdea209a9f2e7db1b30b8d09f8cd48ad8f44f
Timestamp Audit
April 18, 2018 10:41 am MSTRMT Uploaded by Totally Refreshed - totallyrefreshedwaviers@gmail.com IP 184.68.98.146
April 18, 2018 1:12 pm MSTTotally Refreshed - voicemails@totallyrefreshedsteamandspa.com added by Totally Refreshed - voicemails@totallyrefreshedsteamandspa.com as a CC'd Recipient Ip: 184.68.98.146
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