Massage Therapy Paperwork — Back to Health Wellness Centre

Disclaimer*
This form takes approximately 30 minutes to complete. Please ensure that when you have the time to do so, you take the time to read and answer every question; including as many details as possible. THIS IS DONE FOR YOUR OWN SAFETY as our clinic assesses every patient according to their individual needs and uses different techniques and tools to do so!
- I have read and agree to the disclaimer
No Scents Policy*
At Back to Health Wellness Center we have a scents policy. This policy is for the health and comfort of the health care practitioners, employees and patients of Back to Health. Please avoid wearing perfumes, colognes and other personal hygiene products that have any scent. These scents can linger in the air as well as remain on the hands of the health care practitioners as many scents are not easily washed off.
- Yes

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone (cell/primary)*
Phone (home)
Phone (work)
Email*
Current Date*
Sex*
- Male
- Female
Gender*
Birth Date*

Are you or are you possibly pregnant?
- Yes
- No
Expected due date:
Do you exercise regularily?*
- Yes
- No
How many times per week do you exercise?
Please enter a number from 0 to 20.
What are your recreational activities?
Do you have any internal pins, wires, artificial joints or other special equipment (such as a pacemaker or hearing aid)?*
- Yes
- No
Please explain:
Have you ever seen a Massage Therapist?*
- Yes
- No
What is their name?
When was your last treatment?

Our clinic fee schedule can be found here: www.back2health4you.com/clinic-fee-schedule/*
- I have read and agree to the clinic fees
I hereby declare that all of the above information is correct, and if it should change, it is my responsibility to notify the therapist of these changes at the next scheduled appointment.*
- I agree with the above statement.

New Patient Paperwork: Massage Therapy