Euphoria Wellness Mobile

Confidential Client History Form

An accurate health history ensures that it is safe for you to receive a massage treatment, and helps the therapist determine a proper treatment plan. Should your health status change in the future, please let us know.

All information gathered on this form is confidential. Your written authorization is legally required before any of this information can be released.

  • Clients must sanitize hands and must wear a mask for the duration of their treatment and while the RMT is in their home.
  • Clients must provide a working space of 5×10 in order for the RMT to properly and safely perform the treatment.
  • NO Pets or Children can be present during the treatment.

Personal Information

How did you hear about us?

Name (first/last)
Cell#
Cell Provider
Address
City
Postal Code


Email address
As per Canada’s Anti-Spam Legislation (CASL) I consent to receiving electronic messages for promotions and periodic updates only, to the email address above:
YesNo


Occupation
Birth Date (mm/dd/yyyy)


Emergency Contact
Contact Phone#


Driver's License #


• Your place of residence is Detached HomeApartmentCondo/Townhome


Is there ample parking? YesNo


Health Coverage/Direct Billing Information(If Applicable)

Primary Coverage information:

Insurance Company:
Name of Insured:


Relationship: Insured MemberSpouseChild/DependentN/A
Group/Plan Number:


ID Number:



Secondary Coverage information(If Applicable): NOT ALL insurance companies support secondary direct billing - In these instances, secondary coverage must be submitted manually by client.

Insurance Company:
Name of Insured:


Relationship: Insured MemberSpouseChild/DependentN/A
Group/Plan Number:


ID Number:


General Information

Is there a specific area or problem you would like to focus on? If yes, please explain.

Previous Major Illnesses, Operations, Accidents (please give dates):

Explain any other health or medical condition (e.g. haemophilia, diabetes):

Have you had a massage before?
Do you take vitamins?



Are you receiving treatment from any other health care professional?

Medications:

Indicate Conditions Currently or Recently Experienced

Muscle/Joint/Bone/Soft Tissue Discomfort:



Cardiovascular:



Infectious:



Respiratory:



Digestive:



Women:

Pregnancy / Due Date:



Head and Neck:



Skin Conditions (non-contagious):



Other Conditions:

Allergies (eg. Nuts, pollen, etc.)




Waiver (Please read carefully and sign)

  • I attest that the information I have provided is true and complete to the best of my knowledge.
  • I consent to treatments by Massage Therapists at Euphoria Wellness Centre.
  • I understand that I am responsible for any charges incurred in the course of my treatment.
  • I understand 12 hours notice is required to reschedule all appointments, or charges will apply.
  • I understand that No refunds are available on gift cards or massage packages. Packages cannot be combined or exchanged with other offers. Gift cards and packages are non-transferable.
  • Cancellation Fee is $65 with less than 12 hours notice, less than 4 hours will incur the full treatment fee.
  • I release the practitioner from any and all liability from problems arising from the treatment as a result of information given or not given, or incorrectly given in this history form. Because my personal and medical information is confidential, I understand that none of this information will be shared unless I give my consent in writing.
  • For my own safety and for the safety of the public: Intoxication (alcohol use or otherwise) will not be tolerated. Practitioners and/or Management have the right to refuse service should any signs of intoxication be present (eg. odour, slurred speech, belligerence, etc.) before or during my treatment.
    The full cost of the treatment will be charged to my account.


Client Signature:
Date:


Parent/Guardian Signature (if client under 18 years of age)