1st Time Private Consent Form | Kneaded Experience LA

Name *

First

Last

Email *

Cell Phone *

Company *

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth *

(MM/DD/YYYY)

Occupation *

Gender *

Female
Male
Other

Communication with your therapist during your session is essential. Will you agree to be willing to communicate anything you are feeling, whether physical or emotional, to your therapist? *

Yes
No
Unsure

Will you agree to daily fascia stretches as suggested by your therapist? *

Yes
No

Current complaints: *

History of Injuries: *

Any surgeries? *

Any diagnoses? *

Any conditions? *

Please explain any emotional traumas which may be contributing to your conditions. *

Bodywork Goals: *

If you answer “yes” to any of the following questions, please explain as clearly as possible in the additional comments section at the end of the list.

Do you frequently suffer from stress? *

Yes
No

Do you have diabetes? *

Yes
No

Do you experience frequent headaches? *

Yes
No

Are you pregnant? *

Yes
No

Do you suffer from arthritis? *

Yes
No

Are you wearing contact lenses *

Yes
No

Are you wearing dentures? *

Yes
No

Do you have high blood pressure? *

Yes
No

Are you taking high blood pressure medication? *

Yes
No

Do you suffer from epilepsy or seizures? *

Yes
No

Do you suffer from joint swelling? *

Yes
No

Do you have varicose veins? *

Yes
No

Do you have any contagious diseases? *

Yes
No

Do you have osteoporosis? *

Yes
No

Do you have allergies? *

Yes
No

Do you bruise easily? *

Yes
No

Any broken bones in the past 2 years? *

Yes
No

Any injuries in the past 2 years? *

Yes
No

Do you have tension or soreness in a specific area? Please specify in comments. *

Yes
No

Do you have cardiac or circulatory problems? *

Yes
No

Do you suffer from back pain? *

Yes
No

Do you have numbness or stabbing pains? *

Yes
No

Are you sensitive to touch or pressure in any area? Explain in comments. *

Yes
No

Have you ever had surgery? Explain in comments. *

Yes
No

Any other medical condition, or are you taking any medications we should know about? Explain in comments. *

Yes
No

Additional Comments: *

Emergency Contact Name & Phone Number *

Referred by:

Consent to Treatment of Minor: By entering my name below, I herby authorize the therapist to administer bodywork techniques to my child or dependent as they deem necessary.

BY CLICKING THE SUBMIT BUTTON BELOW, I AGREE TO THE FOLLOWING:

I understand that the bodywork I receive is provided for the basic purpose of relaxation and release of muscular tension. If I experience any pain or discomfort during the session, I will immediately inform the practitioner so the pressure and or strokes may be adjusted to my level of comfort. I further understand that 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 specialists for any mental or physical ailment of which I am aware. I understand that 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 should be construed as such. Because bodywork should not be performed under certain medical conditions, I affirm that I have stated all my own medical conditions and answered all questions honestly. I agreed 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. I, as well as all household members, have not been diagnosed nor exposed to anyone diagnosed with any communicable diseases within the last 5 days. I affirm and agree to the above for all subsequent visits.

Send me a copy of my results!

Send me a copy of my results!

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