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?
Devorah Eisenman BHK, RMT
Susan Patterson, 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):