Name* First Last Date*Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Month123456789101112Day12345678910111213141516171819202122232425262728293031Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Main Phone Number*Secondary Phone NumberEmail* Occupation* Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Have you received massage therapy before?*Did a Doctor or other health care practitioner refer you for massage therapy?*If yes, please provide their name and address: Do you have extended health insurance for massage therapy?*If yes, please provide which company? (ex. Greenshield, Manulife etc.)Please note: For direct billing, with many insurance companies a doctor’s note must be submitted prior to first treatment. We recommend contacting your insurance company prior to treatment to fully understand your plan. What goals would you like to achieve with treatment?* Select All Prevention Maintenance Repair Relaxation Other Please select any past or present health issues that you are experiencing or have experienced?* None of these Apply Bones Glandular (thyroid) Urinary Vision/Hearing Stroke or Heart (pacemaker) Muscular Diabetes Epilepsy Digestive Cancer (past or present) Viral (HIV/Hepatitis) Respiratory Low Blood Pressure High Blood Pressure Headaches Infections (hepatitis, TB, herpes) Skin Conditions Migraines Blood Circulation Nervousness Rods/pins/screws Arthritis Osteoporosis Gynecological Disorders Is there any family history of any of the above? Soft tissue or Joint Discomfort* Neck Low Back Shoulders Knees Arms Legs Mid Back Upper Back Hands/Feet What is your primary complaint?*Are you currently pregnant?* Yes No If yes, what is your Due Date? Have you been involved in a motor vehicle accident?* Yes No If yes, please specify when it occurred and what treatment you receivedDo you have any allergies/hypersensitivities to oils or smells? (e.g. aromatherapy)?*If none, please indicate "None". If “yes,” please specify Is there any other medical conditions/information you would like to add?Please describe the areas of the body that you experience pain or discomfort:Current medications?*If none, please indicate "N/A" or "None". Condition it treats:*If none, please indicate "N/A" or "None". Prior or upcoming surgeries*If none, please indicate "N/A" or "None". Is there any additional information you would like to add?I hereby certify that I have read and understand all the questions relative to my health and medical history. I have completed all the information accurately and am aware of no health conditions not specifically mentioned in the case history. I will notify the massage therapist of any changes in my medical profile and agree that there shall be no liability on the therapist’s part should I fail to do so.I understand the massage therapy session I receive is for relaxation, relief of muscular tension or pain, and improving circulation. If I experience discomfort, I will notify the massage therapist. I understand massage therapy is not a substitute for medical examination or treatment, that massage therapists do not diagnose, prescribe, or treat any illness, and that nothing in the course of the session(s) should be construed as such.I hereby absolve Coral Medical Health Spa, and the attending massage therapist of all claims and responsibility for any unwanted effects to my health as a result or consequence of my massage therapy treatment. If I no show or cancel within 24 hours of my appointment I agree to pay my massage therapists no show/last minute cancelation fee. This fee can be up to the full price of treatment. I understand that if I arrive late for an appointment, I am expected to pay for the full session and any extension beyond the originally scheduled ending time will be at the therapist’s discretion.I understand that ANY type of sexual harassment/misconduct is absolutely forbidden. This is defined but not limited to the exposure of any body parts in the “bikini area” (unless I am doing a Brazilian/Bikini treatment), inappropriate touching, sexual innuendo’s, aggressive come-ons, comments about my providers physical appearance or comments which would make my provider fearful or uncomfortable. I also understand that failure to adhere to this policy will result in a lifelong ban from the facility. Consent* I have read everything above and understand it. I consent to to allow Signature Reset signature Signature locked. Reset to sign again
