1. health and fitness
2. therapy

Consent to Participate
PAYMENT POLICY: Payment in full is due on the day of treatment. For your convenience, payment may be made via cash, cheque, or E-­‐transfer. These payments will be made directly to the therapist that is treating you. Cheques payable to the treating therapist.
CANCELLATION POLICY: We understand that you may need to cancel an appointment. Should you need to cancel your scheduled appointment, please notify the clinic via phone or email at least 24 hours in advance. If you fail to notify the clinic within 24 hours, a fee equal to the appointment fee will be applied. This fee will be applied at the discretion of the therapist. We strive to be fair in difficult circumstances such as illness or emergency. FAILURE TO ATTEND: Missed appointments without 24 hour notice will result in a full appointment fee charge. PLEASE NOTE: Kars Massage Therapy DOES NOT provide reminder calls or emails at this time. PRIVACY POLICY: In order to provide treatment, this clinic must collect some personal health information. The privacy policy is posted in the waiting area. Acknowledgment and Consent
I, (print)___________________________________, acknowledge that I have read and understand the policies set out above. I understand that I will be participating in massage treatment, which has been explained to me by my Registered Massage Therapist and hereby consent to treatment. My Registered Massage Therapist has explained what is meant by informed consent and I understand that I may withdraw my consent to treatment at any time. I understand and accept the risks involved in massage therapy as explained by my therapist. I consent to accurately provide information about my health to my therapist to help my therapist provide the best treatment. I understand the privacy policy of this clinic. Signed this ________ day of _________________, 20______ __________________________________ _____________________________ (Patient/legal Guardian) MEDICAL HISTORY INTAKE FORM
All information is kept strictly confidential
NAME (PLEASE PRINT):_____________________________________________________
Home Address: _____________________City:_________ Province:_____________P/C: ____________
Home Phone: ( ) ______________ Work Phone: ( ) _______________ Cell: ( ) ______________
Email:______________________________________________________________________________
( ) I give permission for the clinic to contact me via mail or email (e.g. Newsletters, cards, etc)
Date of Birth: (Month/ Day/ Year) ______________________ Occupation: ________________________
Dr. Name: ________________________ Dr. Phone/Address:__________________________________
Emergency Contact: Name_____________________________ Phone:__________________________
How did you find us?
Clinic web site( ) Mailout( ) Facebook( ) Drove By( ) Referral( ) Other:__________________
I give permission to thank the person who referred me and mention my name: Yes( )
No( )
Main reason for seeking Massage Therapy:
___________________________________________________________________________________
Have you had massage before? Yes( )
No( )
Last Apt.?________________________________
Other health care in past year? (Please circle all that apply)
Chiro, Physio, Osteopathy, Acupuncture, Naturopath,
Other: ___________________________
Current Medications:
1.______________________________________ Reason:____________________________________
2.______________________________________ Reason:____________________________________
3.______________________________________ Reason:____________________________________
Please List All Surgeries, Car Accidents and Injuries:
1._______________________________________ Date:_____________________________________
2._______________________________________ Date:_____________________________________
3._______________________________________ Date:_____________________________________
Describe your physical activities: ________________________________________________________
___________________________________________________________________________________
Describe your job activities:_____________________________________________________________
___________________________________________________________________________________
Please circle all
areas of discomfort.
Please check any condition below that you are currently experiencing or have had in the past.
While some conditions may not seem related to Massage Therapy, it is important that we have a
complete picture of your current and past health history.
General Heath:
□ Poor
□ Fair
□ Good □ Excellent
Arthritic Conditions:
□ Ankylosing Spondylitis
□ Degenerative Discs
□ Gout
□ Osteoarthritis
Where: _____________
□ Rheumatoid Arthritis
□ Other Arthritis
Genitourinary System:
□ Urination Problems
□ Kidney/Bladder
□ Pelvic Floor Dysfunction
□ Prostate issues
□ Incontinence
□ Other
Gastro/Intestinal:
□ Constipation
□ Gas/Bloating
□ Nausea
□ Irritable Bowel
Respiratory Conditions: □ Crohns
□ Asthma
□ Liver/Gall Bladder
□ Pneumonia
□ Other____________
□ Chronic Bronchitis
□ Emphysema
Circulatory Conditions:
□ Sinusitis
□ Heart Attack/Stroke
□ Sinus congestion
□ Angina
□ Shortness of breath
□ Heart palpitations
□ Chronic cough
□ Blood Pressure
□ Tuberculosis
□High □Low ____/____
□ COPD
□ Arteriosclerosis
□ Other: ____________
□ Arteritis-inflamed artery
□ Phlebitis-inflamed veins
Nervous System:
□ Varicose Veins
□ Epilepsy/convulsions
□ Aneurysm
□ Paralysis
□ Thrombosis
□ Multiple Sclerosis
□ Blood Clots
□ Numbness/tingling
□ Raynaud’s Disease
□ Other: ____________
□ Buerger’s Disease
□ Other: _____________
Do you have any internal
pins, wires, artificial
Blood Conditions:
joints, pacemaker or
□ Anaemia
special equipment?
□ Haemophilia
□ No
□ Yes
□ Leukemia
Where:______________ □ Other: _____________
Systemic Conditions:
□ Allergies:__________
□ anaphalactic?
□ Epipen?
□ Diabetes
□ Fatigue Problems
□ Lupus
□ Fibromyalgia
□ Fever/chills/sweats
□ Fainting/dizziness
□ HIV/AIDS
□ Infectious Diseases:
_________________
□ Other____________
Musculo-Skeletal:
□ Osteoporosis
□ Joint or bone disease
□ Tendonitis/ Bursitis
□ Sprain/Strain
□ Spasms/Cramps
□ Head Aches/Migraines
□ Jaw Pain/ TMJ
□ Other: ___________
Other Conditions:
□ Cancer/Tumours
When?____________
What type?_________
□ Alcohol/ Drug
For Women:
Addiction
□ Pregnant Due
□ Vision Problems
Date:_______
□ Hearing Problems
# Preg.: ___
□ Anxiety
# Children:___
□ Depression
□ Infertility
□ Dental problems
□ Menstrual Problems
□ TMJ
□ Menopausal Problems □ Loss of sleep/insomnia
□ Endometriosis
□ Thyroid Disorders
□ Fibroids
□ Hernia
□ Breast Issues
Where?_____
□ Other: __________
□ Please include and
Skin Conditions:
describe all other health
□ Hypersensitivity/hives concerns below:
_________________________
□ Bruises easily
_________________________
□ Rashes/itching
_________________________
□ Skin Conditions
_________________________
□ Poor healing
_________________________
□ Eczema
_________________________
□ Athletes Foot
_________________________
_________________________
□Warts
_________________________
□ Other:___________
_________________________
_________________________
Date:______________________ Signature:_______________________________
Update 1: __________Initials:_____ Update 2: __________Initials:_____ Update 3: _______Initials:____