All personal information, files and verbal discussionsthat take place inside the center, is confidential. Privacy of personal information is very important to Well Life Institute and Wellness Center. We are committed to collecting, using and disclosing personal information only for purposes that are required for the services we provide.

Personal Information is, but not limited to:    Anyrelate information that s to ones personal characteristics, health, activities and views. 

Why We Collect Personal Information:    Like many Medical/Naturopathic Practices, we collect, use and disclose personal informatin in order to best treat our clients.  The primary purpose of collecting personal information is to provide each client with the utmost respect and client care available. Personal information is used to help assess each individuals health needs, and advise them of their best options, and protect both client and specialist. 

Keeping and Protecting Client Files:     It is required that we keep client files should clients need any information within their files for 7 - 10 years from their last appointment. We understand the importance of protecting client files. To insure that protection, We keep paper information in a secure and locked filing cabinet.  We provide electronic hardware that is safe coded with passwords., Paper information is only transmitted through sealed, addressed envelopes and/or boxes. External consultants or agsencies which have access must enter into privacy agreements.  We do not share your files with other offices or individuals without written expressed consent.

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Information obtained in this form helps us to better help you with the modality of massage for your individual needs.


Review Privacy Policy

NOTICE
If you are having symptoms of a cold, flu or of covid-19 or have had a fever, infection or other conditions that are contraindicated to massage, please let therapist Know in order to make special arrangements.
 

 

By signing below you agree to the following.

I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time.

Date: September 28, 2021

First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Information

Evening Phone

Occupation

Employer

Primary Physician

Medical Information

Are you taking any medications?*
No
Yes

If yes, please list name and use:
Are you currently pregnant?*
No
Yes

If yes, how far along?

Any high risk factors?
Do you suffer from chronic pain?*
No
Yes

If yes, please explain

What makes it better?

What makes it worse?
Have you had any orthopedic injuries?*
No
Yes

If yes, please list
Please indicate any of the following that apply to you.
Cancer
Headaches/Migraines
Arthritis
Diabetes
Joint Replacement(s)
High/Low Blood Pressure
Neuropathy
Fibromyalgia
Stroke
Heart Attack
Kidney Dysfunction
Blood Clots
Numbness
Sprains or Strains

Explain any conditions you have marked above:

Massage Information

Have you had a professional massage before?*
No
Yes
What type of massage are you seeking?
Relaxation
Therapeutic/Deep Tissue

Other
What pressure do you prefer?*
Light
Medium
Deep
Do you have any allergies or sensitivities?*
No
Yes

Please explain
Are there any areas (feet, face, abdomen, etc.) you do not want massaged?*
No
Yes

Please explain

What are your goals for this treatment session?
First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Information

Evening Phone

Occupation

Employer

Primary Physician

Medical Information

Are you taking any medications?*
No
Yes

If yes, please list name and use:
Are you currently pregnant?*
No
Yes

If yes, how far along?

Any high risk factors?
Do you suffer from chronic pain?*
No
Yes

If yes, please explain

What makes it better?

What makes it worse?
Have you had any orthopedic injuries?*
No
Yes

If yes, please list
Please indicate any of the following that apply to you.
Cancer
Headaches/Migraines
Arthritis
Diabetes
Joint Replacement(s)
High/Low Blood Pressure
Neuropathy
Fibromyalgia
Stroke
Heart Attack
Kidney Dysfunction
Blood Clots
Numbness
Sprains or Strains

Explain any conditions you have marked above:

Massage Information

Have you had a professional massage before?*
No
Yes
What type of massage are you seeking?
Relaxation
Therapeutic/Deep Tissue

Other
What pressure do you prefer?*
Light
Medium
Deep
Do you have any allergies or sensitivities?*
No
Yes

Please explain
Are there any areas (feet, face, abdomen, etc.) you do not want massaged?*
No
Yes

Please explain

What are your goals for this treatment session?
Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Information

Evening Phone

Occupation

Employer

Primary Physician

Medical Information

Are you taking any medications?*
No
Yes

If yes, please list name and use:
Are you currently pregnant?*
No
Yes

If yes, how far along?

Any high risk factors?
Do you suffer from chronic pain?*
No
Yes

If yes, please explain

What makes it better?

What makes it worse?
Have you had any orthopedic injuries?*
No
Yes

If yes, please list
Please indicate any of the following that apply to you.
Cancer
Headaches/Migraines
Arthritis
Diabetes
Joint Replacement(s)
High/Low Blood Pressure
Neuropathy
Fibromyalgia
Stroke
Heart Attack
Kidney Dysfunction
Blood Clots
Numbness
Sprains or Strains

Explain any conditions you have marked above:

Massage Information

Have you had a professional massage before?*
No
Yes
What type of massage are you seeking?
Relaxation
Therapeutic/Deep Tissue

Other
What pressure do you prefer?*
Light
Medium
Deep
Do you have any allergies or sensitivities?*
No
Yes

Please explain
Are there any areas (feet, face, abdomen, etc.) you do not want massaged?*
No
Yes

Please explain

What are your goals for this treatment session?
Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Information

Evening Phone

Occupation

Employer

Primary Physician

Medical Information

Are you taking any medications?*
No
Yes

If yes, please list name and use:
Are you currently pregnant?*
No
Yes

If yes, how far along?

Any high risk factors?
Do you suffer from chronic pain?*
No
Yes

If yes, please explain

What makes it better?

What makes it worse?
Have you had any orthopedic injuries?*
No
Yes

If yes, please list
Please indicate any of the following that apply to you.
Cancer
Headaches/Migraines
Arthritis
Diabetes
Joint Replacement(s)
High/Low Blood Pressure
Neuropathy
Fibromyalgia
Stroke
Heart Attack
Kidney Dysfunction
Blood Clots
Numbness
Sprains or Strains

Explain any conditions you have marked above:

Massage Information

Have you had a professional massage before?*
No
Yes
What type of massage are you seeking?
Relaxation
Therapeutic/Deep Tissue

Other
What pressure do you prefer?*
Light
Medium
Deep
Do you have any allergies or sensitivities?*
No
Yes

Please explain
Are there any areas (feet, face, abdomen, etc.) you do not want massaged?*
No
Yes

Please explain

What are your goals for this treatment session?
Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Information

Evening Phone

Occupation

Employer

Primary Physician

Medical Information

Are you taking any medications?*
No
Yes

If yes, please list name and use:
Are you currently pregnant?*
No
Yes

If yes, how far along?

Any high risk factors?
Do you suffer from chronic pain?*
No
Yes

If yes, please explain

What makes it better?

What makes it worse?
Have you had any orthopedic injuries?*
No
Yes

If yes, please list
Please indicate any of the following that apply to you.
Cancer
Headaches/Migraines
Arthritis
Diabetes
Joint Replacement(s)
High/Low Blood Pressure
Neuropathy
Fibromyalgia
Stroke
Heart Attack
Kidney Dysfunction
Blood Clots
Numbness
Sprains or Strains

Explain any conditions you have marked above:

Massage Information

Have you had a professional massage before?*
No
Yes
What type of massage are you seeking?
Relaxation
Therapeutic/Deep Tissue

Other
What pressure do you prefer?*
Light
Medium
Deep
Do you have any allergies or sensitivities?*
No
Yes

Please explain
Are there any areas (feet, face, abdomen, etc.) you do not want massaged?*
No
Yes

Please explain

What are your goals for this treatment session?
Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Information

Evening Phone

Occupation

Employer

Primary Physician

Medical Information

Are you taking any medications?*
No
Yes

If yes, please list name and use:
Are you currently pregnant?*
No
Yes

If yes, how far along?

Any high risk factors?
Do you suffer from chronic pain?*
No
Yes

If yes, please explain

What makes it better?

What makes it worse?
Have you had any orthopedic injuries?*
No
Yes

If yes, please list
Please indicate any of the following that apply to you.
Cancer
Headaches/Migraines
Arthritis
Diabetes
Joint Replacement(s)
High/Low Blood Pressure
Neuropathy
Fibromyalgia
Stroke
Heart Attack
Kidney Dysfunction
Blood Clots
Numbness
Sprains or Strains

Explain any conditions you have marked above:

Massage Information

Have you had a professional massage before?*
No
Yes
What type of massage are you seeking?
Relaxation
Therapeutic/Deep Tissue

Other
What pressure do you prefer?*
Light
Medium
Deep
Do you have any allergies or sensitivities?*
No
Yes

Please explain
Are there any areas (feet, face, abdomen, etc.) you do not want massaged?*
No
Yes

Please explain

What are your goals for this treatment session?
Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Information

Evening Phone

Occupation

Employer

Primary Physician

Medical Information

Are you taking any medications?*
No
Yes

If yes, please list name and use:
Are you currently pregnant?*
No
Yes

If yes, how far along?

Any high risk factors?
Do you suffer from chronic pain?*
No
Yes

If yes, please explain

What makes it better?

What makes it worse?
Have you had any orthopedic injuries?*
No
Yes

If yes, please list
Please indicate any of the following that apply to you.
Cancer
Headaches/Migraines
Arthritis
Diabetes
Joint Replacement(s)
High/Low Blood Pressure
Neuropathy
Fibromyalgia
Stroke
Heart Attack
Kidney Dysfunction
Blood Clots
Numbness
Sprains or Strains

Explain any conditions you have marked above:

Massage Information

Have you had a professional massage before?*
No
Yes
What type of massage are you seeking?
Relaxation
Therapeutic/Deep Tissue

Other
What pressure do you prefer?*
Light
Medium
Deep
Do you have any allergies or sensitivities?*
No
Yes

Please explain
Are there any areas (feet, face, abdomen, etc.) you do not want massaged?*
No
Yes

Please explain

What are your goals for this treatment session?
Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Information

Evening Phone

Occupation

Employer

Primary Physician

Medical Information

Are you taking any medications?*
No
Yes

If yes, please list name and use:
Are you currently pregnant?*
No
Yes

If yes, how far along?

Any high risk factors?
Do you suffer from chronic pain?*
No
Yes

If yes, please explain

What makes it better?

What makes it worse?
Have you had any orthopedic injuries?*
No
Yes

If yes, please list
Please indicate any of the following that apply to you.
Cancer
Headaches/Migraines
Arthritis
Diabetes
Joint Replacement(s)
High/Low Blood Pressure
Neuropathy
Fibromyalgia
Stroke
Heart Attack
Kidney Dysfunction
Blood Clots
Numbness
Sprains or Strains

Explain any conditions you have marked above:

Massage Information

Have you had a professional massage before?*
No
Yes
What type of massage are you seeking?
Relaxation
Therapeutic/Deep Tissue

Other
What pressure do you prefer?*
Light
Medium
Deep
Do you have any allergies or sensitivities?*
No
Yes

Please explain
Are there any areas (feet, face, abdomen, etc.) you do not want massaged?*
No
Yes

Please explain

What are your goals for this treatment session?
Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Information

Evening Phone

Occupation

Employer

Primary Physician

Medical Information

Are you taking any medications?*
No
Yes

If yes, please list name and use:
Are you currently pregnant?*
No
Yes

If yes, how far along?

Any high risk factors?
Do you suffer from chronic pain?*
No
Yes

If yes, please explain

What makes it better?

What makes it worse?
Have you had any orthopedic injuries?*
No
Yes

If yes, please list
Please indicate any of the following that apply to you.
Cancer
Headaches/Migraines
Arthritis
Diabetes
Joint Replacement(s)
High/Low Blood Pressure
Neuropathy
Fibromyalgia
Stroke
Heart Attack
Kidney Dysfunction
Blood Clots
Numbness
Sprains or Strains

Explain any conditions you have marked above:

Massage Information

Have you had a professional massage before?*
No
Yes
What type of massage are you seeking?
Relaxation
Therapeutic/Deep Tissue

Other
What pressure do you prefer?*
Light
Medium
Deep
Do you have any allergies or sensitivities?*
No
Yes

Please explain
Are there any areas (feet, face, abdomen, etc.) you do not want massaged?*
No
Yes

Please explain

What are your goals for this treatment session?
Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Information

Evening Phone

Occupation

Employer

Primary Physician

Medical Information

Are you taking any medications?*
No
Yes

If yes, please list name and use:
Are you currently pregnant?*
No
Yes

If yes, how far along?

Any high risk factors?
Do you suffer from chronic pain?*
No
Yes

If yes, please explain

What makes it better?

What makes it worse?
Have you had any orthopedic injuries?*
No
Yes

If yes, please list
Please indicate any of the following that apply to you.
Cancer
Headaches/Migraines
Arthritis
Diabetes
Joint Replacement(s)
High/Low Blood Pressure
Neuropathy
Fibromyalgia
Stroke
Heart Attack
Kidney Dysfunction
Blood Clots
Numbness
Sprains or Strains

Explain any conditions you have marked above:

Massage Information

Have you had a professional massage before?*
No
Yes
What type of massage are you seeking?
Relaxation
Therapeutic/Deep Tissue

Other
What pressure do you prefer?*
Light
Medium
Deep
Do you have any allergies or sensitivities?*
No
Yes

Please explain
Are there any areas (feet, face, abdomen, etc.) you do not want massaged?*
No
Yes

Please explain

What are your goals for this treatment session?
Client's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*

How did you hear about us?
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Evening Phone

Occupation

Employer

Primary Physician

Medical Information

Are you taking any medications?*
No
Yes

If yes, please list name and use:
Are you currently pregnant?*
No
Yes

If yes, how far along?

Any high risk factors?
Do you suffer from chronic pain?*
No
Yes

If yes, please explain

What makes it better?

What makes it worse?
Have you had any orthopedic injuries?*
No
Yes

If yes, please list
Please indicate any of the following that apply to you.
Cancer
Headaches/Migraines
Arthritis
Diabetes
Joint Replacement(s)
High/Low Blood Pressure
Neuropathy
Fibromyalgia
Stroke
Heart Attack
Kidney Dysfunction
Blood Clots
Numbness
Sprains or Strains

Explain any conditions you have marked above:

Massage Information

Have you had a professional massage before?*
No
Yes
What type of massage are you seeking?
Relaxation
Therapeutic/Deep Tissue

Other
What pressure do you prefer?*
Light
Medium
Deep
Do you have any allergies or sensitivities?*
No
Yes

Please explain
Are there any areas (feet, face, abdomen, etc.) you do not want massaged?*
No
Yes

Please explain

What are your goals for this treatment session?
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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