New client consent form Name* First Last Phone*Email* Date of birth* DD slash MM slash YYYY Address* Street Address Address Line 2 City ZIP / Postal Code OccupationHow did you hear about us? Friend Socials Google/Web Other How do you spend your day?* Seated Standing What is your intent for your massage?Reason for treatmentHave you ever experienced any of the following?* Broken bones Disc problems Muscle strain/sprain Nerve pain High/low blood pressure Heart condition Anxiety/Depression Varicose veins/blood clots Arthritis Sleep disorders Osteoporosis Numbness or tingling anywhere Autoimmune disease If you answered yes to any of the above questions, please provide further information here.Are you pregnant?* No Yes How many weeks?Treatment consent I have to the best of my knowledge, provided all relevant information about my health and medical history and I give my full consent to Remedial massage treatment. I intend this consent to apply to all future treatments and understand that I must update The Humble Nook (my service provider) with any changes that may occur in my medical history. I understand that a 75% cancellation fee may apply if I do not provide at least 24 hours notice. Those under 18 years of age must have this form signed by a parent or guardian. I consent to treatment Name*Signature*Date MM slash DD slash YYYY
