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!!ELECTRONIC APPLICATION FORM FOR TREATMENT!!
"ALL DATA IS SECURED"
Soifah Thai Massage Application for Treatment Information Required by Texas Occupational Code 455
Home Phone: Cell Phone: Wk Phone:
Email Address:
Therapeutic services are a non-sexual health-care. At no time during the massage will the therapist massage genitalia, and I understand that this massage is given in a strictly non-sexual manner. Unless otherwise stated in treatment notes or by you, you will receive a full body massage. In all massage modalities and sessions, draping will be used. Massage is a service intended for enhancing your health and quality of life. If at any time you are uncomfortable with the massage, please inform the therapist and he/she will gladly rectify the problem, including ending the session if you upon your request..
Are you under the care of another health care practitioner for this condition? (yes/no)
If so whom: Provider's Phone: List any medical conditions, surgeries and/or diagnosis with-in the last 5 years. Include any allergies:Maybe Added Here.
Are you taking medication for high blood pressure or diadetes ? (Yes/No)
Are you Pregnant? (Yes/No)
IF PAIN IS A FACTOR PLEASE COMPLETE THE FOLLOWING!
If there is a diagnosed injury involved please state? When did it start, and what makes it better?
What makes it worse?
Pain with motion? (Yes/No)
What do you hope to gain from this treatment?
Voluntary: How did you learn of our services?
I release Soifah Thai Massage from any responsibility for pre-existing conditions I have not revealed or any consequential changes to those conditions that arise subsequent to the treatment. I further agree my signature on this document is as valid as if I signed the document in writing. This is to be used in conjunction with the use of electronic signatures on all forms regarding any and all future documentation with a signature requirement, should I elect to have signed electronically. Client's Electronic Signature: Date:
I further agree my signature on this document is as valid as if I signed the document in writing. This is to be used in conjunction with the use of electronic signatures on all forms regarding any and all future documentation with a signature requirement, should I elect to have signed electronically. Client's Electronic Signature:
Signature of Legal Guardian if under the age of 17
