For ALL IN-CLINIC Patients, It is required to fill out this screening questionnaire for EACH VISIT to the clinic
Date of Birth
Which therapist will you be attending?
Amanda Williams RMT
James Holden, RMT
Clara Ebert, RMT
I have requested assessment and/or treatment by the above Registered Massage Therapist (RMT) for treatment of the clinically relevant areas indicated below.
(*) Please initial beside each:
[Buttocks (gluteal Muscles)
[Chest Wall Muscles
[Upper Inner Thigh(s)
The RMT has explained the following to me and I fully understand the proposed assessment and/or treatment:
• The nature of the assessment, including the clinical reason(s) for assessment of the above areas(s) and the draping methods to be used • The expected benefits of the assessment • The potential risks of the assessment • The potential side effects of the assessment • That consent is voluntary • That I can withdraw or alter my consent at any time
I voluntarily give my informed consent for the assessment and/or treatment as discussed and outlined above.
Guardian name (leave blank if patient is over 18):
I have answered all the above questions honestly and truthfully