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Massage Therapist Rachel Porter (Revive Therapeutics)

Client Information

First Name*

Last Name*

Gender

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Address

City

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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

I agree to receive massage therapy for therapeutic purposes. The treatment plan does not include sensitive areas of the body such as buttocks or breasts unless I give consent to have those addressed (see the consent below). I can bring a witness to be present during my massage. 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 on additional areas of the body

After having discussed the treatment plan with the massage therapist — including the purpose and draping protocol — I consent to receive treatment on the following areas of the body not typically included in treatment without understanding the therapeutic intent:
I can revoke this consent at any time.
I have read and agree to the additional consent forms and policies in My Documents that were provided to me by the massage therapist or clinic.

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Theraphy and Patient Charting

Health Care Provider

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