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
Name
Date of Birth*
Day:
Month:
January
February
March
April
May
June
July
August
September
October
November
December
Year:
Which therapist will you be attending?
Devorah Eisenman BHK, RMT
Susan Patterson, RMT
Other
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.
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Guardian name (leave blank if patient is over 18):
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Signature
