For ALL IN-CLINIC Patients, It is required to fill out this screening questionnaire for EACH VISIT to the clinic

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    Consent Form
    1. Date of Birth*
      Day: Month: Year:
    2. Devorah Eisenman BHK, RMTSusan Patterson, RMTMaria Buzas, RMTOther
    3. I have requested assessment and/or treatment by the above Registered Massage Therapist (RMT) for treatment of the clinically relevant areas indicated below.

    4. (*) Please initial beside each:
    5. [Buttocks (gluteal Muscles) [Chest Wall Muscles [Upper Inner Thigh(s)
    6. The RMT has explained the following to me and I fully understand the proposed assessment and/or treatment:
    7. • 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
    8. I voluntarily give my informed consent for the assessment and/or treatment as discussed and outlined above.
    9. ———–

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    Signature