Client Information and Consent to Treatment
City:__________________________________ State:_________ Zip:____________
Day:_______________________ Evening:__________________ Cell:_______________
Date of birth:____________________________ Gender:__________________________
May I leave messages with your spouse, partner, or other person? Yes______ No______
State name & relationship:___________________________________________________
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.
If the client is under 18 years old, please complete the following:
Name of legal parent or guardian:______________________________________________
May I leave messages with your spouse, partner or other person? Yes______ No_______
State name & relationship:____________________________________________________