Client Information and Consent to Treatment



Name:__________________________________________________________________

 

Address:________________________________________________________________

 

City:__________________________________         State:_________ Zip:____________

 

Phone 

Day:_______________________ Evening:__________________ Cell:_______________

 

Date of birth:____________________________  Gender:__________________________

 

May I leave messages with your spouse, partner, or other person?  Yes______  No______

 

State name & relationship:___________________________________________________

 

Emergency Contact:

 

Name:___________________________________________________________________

 

Relationship:_____________________________  Phone:__________________________


 

Please provide 24 hours cancellation notice if you are unable to keep your appointment.

If 24 hours is not given, you will be charged for the appointment.


 

I,_______________________________________________________, hereby request and consent to treatment from Anna Cherekovsky, CMT.  I understand that my treatment may require the provision of varied therapies, including, but not limited to, Acupressure, Structural Alignment, CranioSacral Therapy, and Visceral Manipulation.  I realize that the particular therapeutic outcomes of these treatments, individually and jointly, cannot be predicted with certainty and no guarantee is made regarding any particular result or outcome.

 

I understand that close contact with people increases the risk of infection from COVID-19.  

By signing this form, I acknowledge that I am aware of the risks involved and give consent to receive bodywork from Anna Cherekovsky.


I understand that my name and contact information might be shared with the State Health Department in the event that a client or practitioner at this clinic tests positive for COVID-19.

My contact details will only be shared in the event they are relevant, based on suspected exposure date, and only for appropriate follow-up by the Health Department. 


SIgned:_________________________________________  Date:____________________


 

If the client is under 18 years old, please complete the following:

 

Name of legal parent or guardian:______________________________________________

 

Phone

Day:_________________________Evening:___________________ Cell:______________

 

May I leave messages with your spouse, partner or other person?  Yes______  No_______

 

State name & relationship:____________________________________________________