Laura Nicole, Therapy for Body & Soul
NC License #18446
PRINT Client Name: ________________________________ Date: ___________________________
Email:____________________________________________________
Phone number: _____________________________ Birthday: _______________________
Referred By: _________________________________
Emergency Contact & Phone #: _______________________________________________________
Any specific areas that need extra attention: ____________________________________________
Any bruises, open wounds, broken bones, recent treatments/surgeries: ___________________
Any specific areas to avoid: _____________________________________________________
Allergies: ______________________________________________________________________
Are you Pregnant: ______ No ______ Yes Due Date: ______________
Do you have a pacemaker or any metal in your body? _______ No _______Yes
Consent for Treatment: If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage/bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. Understanding all of this, I give my consent to receive care.
Client Signature: _________________________________ Date: __________________________