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Massage Therapist Rachel Porter (Revive Therapeutics)

Client Information

First Name*

Last Name*

Gender

Male Female Other

Address

City

State

Zip/Postal

Phone* (numbers only)

Date of Birth *mm/dd/yyyy

Email *

Confirm Email *

Create/Update User ID*

Create/Update Password*

Confirm Password*

Text Messages (optional)

Mobile Phone (numbers only)

I CONSENT to the practice contacting me by text message for the purpose of health information and appointment reminders. I will ensure that I keep the practice informed of my up-to-date mobile number at all times, or if the number is no longer in my possession.

Additional Contact Information

Emergency Contact

Name

Phone (numbers only)

Relationship to You

I give my consent to receive massage therapy

By checking the Consent Box, I am am agreeing to receive massage therapy for therapeutic purposes. I can have a witness present during my massage, and I'll provide the witness. If I'm under 18 years old, my parents or guardian can choose to be present during my massage. I can revoke this consent at any time.
I give my consent to receive treatment or to vary the draping protocol in these additional areas (see text box below) for therapeutic purposes

I am checking this box after the massage therapist and I have discussed the purpose, draping, and treatment plan involved.
I can revoke this consent at any time.

Select the reason for seeking care

Wellness (relaxation, stress reduction, or performance enhancement)
Treatment (pain, injury, medical condition, pregnancy)

Note: You will be given additional intake forms to complete based on your condition and current needs.

* Required fields

Theraphy and Patient Charting

Health Care Provider

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