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                                                    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:___________________________________________________


Emergency Contact:




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:______________________________________________



Day:_________________________Evening:___________________ Cell:______________


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


State name & relationship:____________________________________________________

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