Client Sign-in

Client Registration Form

 
Patient Sign-in
New Client Registration
Medical History
Client Medical History

Client Registration( * mandatory to fill )

Is the Client under 18?
Yes
No

Guardian Information

How do we contact you?( * mandatory to fill )

Who do we contact in case of an emergency?( * mandatory to fill )

Personal goals

Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

(All questions are required * )

Are you under a physicians care now?
Yes
No
Have you ever had a serious head or neck injury?
Yes
No
Are you taking any medication, pills or drugs?
Yes
No

Please take a moment to carefully read the following information and sign where indicated. If you have a specific medical condition or specific symptoms, massage/bodywork may be contraindicated. A referral from your primary care provider may be required prior to service being provided

Do you see a chiropractor?
Yes
No
Are you currently under medical care?
Yes
No
I have answered all the above questions

Medical History

Are you a woman?
Yes
No
Are you allergic to any of the following?
I have answered all the above questions

Medical History

Do you or have you experienced the following?

AIDS/HIV Positive
Yes
No
Allergic Reactions
Yes
No
Sensitive Skin
Yes
No
Alzheimers disease
Yes
No
Anaphylaxis
Yes
No
Anemia
Yes
No
Angina
Yes
No
Arthritis/Gout
Yes
No
Artificial Heart Valves
Yes
No
Artificial Bones/Joints
Yes
No
Asthma
Yes
No
Blood Disease
Yes
No
Blood Transfusion
Yes
No
Breathing Problems
Yes
No
Bruise Easily
Yes
No
Cancer
Yes
No
Chemotheropy
Yes
No
Chest Pain
Yes
No
Cold sores / Fever blisters
Yes
No
Congenital heart disorder
Yes
No
Convulsion
Yes
No
Cortisone medicine
Yes
No
Diabetes
Yes
No
Difficulty Breathing
Yes
No
Drug Addiction
Yes
No
Easily Winded
Yes
No
Emphysema
Yes
No
Epilepsy or Seizures
Yes
No
Excessive Bleeding
Yes
No
Excessive Thirst
Yes
No
Fainting spells / Dizziness
Yes
No
Frequent Cough
Yes
No
Frequent Diarrhea
Yes
No
Frequent Headaches
Yes
No
Genital Herpes
Yes
No
Glaucoma
Yes
No
Hay Fever
Yes
No
Heart Attack / Failure
Yes
No
Heart Murmer
Yes
No
Heart Pacemaker
Yes
No
Heart Trouble / Desease
Yes
No
Hemophilea
Yes
No
Hepatitis A
Yes
No
Hepatitis B or C
Yes
No
Herpes
Yes
No
High Blood Pressure
Yes
No
High Cholesterol
Yes
No
Hives or Rash
Yes
No
Hypoglycemia
Yes
No
Irregular Heartbeat
Yes
No
Kidney Problem
Yes
No
Leukemia
Yes
No
Liver Disease
Yes
No
Low Blood Pressure
Yes
No
Lung diseases
Yes
No
Mitral Value prolapse
Yes
No
Osteoporosis
Yes
No
Pain in Jaw Joints
Yes
No
Parathyroid Disease
Yes
No
Psychiatric Care
Yes
No
Radiation Treatments
Yes
No
Recent Weight Loss
Yes
No
Renal Dialysis
Yes
No
Rheumatic Fever
Yes
No
Rheumatism
Yes
No
Scarlet Fever
Yes
No
Shingles
Yes
No
Sickle Cell Disease
Yes
No
Sinus Trouble
Yes
No
Spina Bifida
Yes
No
Stomach/Intestinal Disease
Yes
No
Stroke
Yes
No
Swelling of Limbs
Yes
No
Thyroid Disease
Yes
No
Tonsillitis
Yes
No
Tuberculosis
Yes
No
Tumors or Growths
Yes
No
Ulcers
Yes
No
Venereal Disease
Yes
No
Yellow Jaundice
Yes
No
Have you ever had serious illnesses not listed?
Yes
No
I have answered all the above questions

Massage Information

Have you ever had professional massage before?
Yes
No
What kind of pressure do you prefer?
Light
Medium
Firm
What type of massage are you seeking today?
Are you sensitive to fragrances or perfumes?
Yes
No
Do you have sensitive skin?
Yes
No
Do you wear contact lenses?
Yes
No
Do you exercise regularly?
Yes
No
Please use the body diagrams to the right to indicate any areas you would like the massage therapist to concentrate on.

Treatment Authorization

The information on this page is correct to the best of my knowledge. I HAVE provided all of my known physical and medical conditions and I certify to the above statements regarding my medical condition. I understand that the services provided are for the basic purpose of relief of ailment and overall relaxation. I further understand that this message is not a substitute for medical examination, diagnosis or treatment. I authorize and give consent to receive therapy. If I experience any discomfort or pain during the session, I will immediately inform the staff.

SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

Office Financial Policy

Payment is expected at time of service. We will accept cash or credit card.

SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

Recieve Appointment Reminders Via Email And Text

Please check a source in which you would like to recieve appointment reminders.*

Email  
Text Message  
Both Email and Text Message

We use this information to provide you with excellent care. We may disclose Patient Health Information (PHI) to third parties that perform services for the spa in the administration of your benefits in accordance with HIPAA. These parties are required by law to sign a contract agreeing to protect the confidentiality of your PHI. Your PHI may be disclosed to an affiliate that performs services for the spa in the administration of your benefits. Our affiliates do not sell, share or rent our users’ personally identifiable information unless required by law, do not send and e-mail or other communications without user permission, and do not send spam.

Thank you for visiting Essential Body Bar. We want your visit to be pleasant and comfortable.Please help us by completing this form
Client Information

Personal Details

Title: First Name: Last Name: Date Of Birth: Gender: Occupation: Physician:
Is the Client under 18? Yes No

Guardian Details

First Name: Last Name: Date Of Birth: Phone Number: Relation to Client:

Address

Street Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Email Address:

Emergency Contact Information

Name: Relation: Home Phone: Work Phone: Address: City: State: Zip Code:

Professional Information

Employer Name: Position: Employer Address: City: State: Zip Code:

What are your personal goals for this treatment?


Medical History
Are you under a physicians care now?
Yes
No
Details:
Have you ever had a serious head or neck injury?
Yes
No
Details:
Are you taking any medication, pills or drugs?
Yes
No
Details:
Please take a moment to carefully read the following information and sign where indicated. If you have a specific medical condition or specific symptoms, massage/bodywork may be contraindicated. A referral from your primary care provider may be required prior to service being provided

Do you suffer from chronic or persistent pain/discomfort? If so, for how long?
Do you know what caused it/what makes the symptoms better or worse?
Do you see a chiropractor? Yes No
Are you currently under medical care? Yes No
Are you a woman?
Yes
No
Pregnant/trying to get pregnant Nursing Taking oral contraceptives None
Are you allergic to any of the following?
Aspirin Penicillin Codeine Acrylic
Metal Latex Sulfa drugs Local anesthetics
Fragrances Oils Nuts Others
Details:
Details:
Do you or Have you experienced the following ?
AIDS/HIV Positive Alzheimers disease Anaphylaxis
Anemia Angina Arthritis/Gout
Artificial Heart Valves Artificial Bones/Joints Asthma
Blood Disease Blood Transfusion Breathing Problems
Bruise Easily Cancer Chemotheropy
Chest Pain Cold sores / Fever blisters Congenital heart disorder
Convulsion Cortisone medicine Diabetes
Difficulty Breathing Drug Addiction Easily Winded
Emphysema Epilepsy or Seizures Excessive Bleeding
Excessive Thirst Fainting spells / Dizziness Frequent Cough
Frequent Diarrhea Frequent Headaches Genital Herpes
Glaucoma Hay Fever Heart Attack / Failure
Heart Murmer Heart Trouble / Desease Hemophilea
Hepatitis A Hepatitis B or C Herpes
High Blood Pressure High Cholesterol Hives or Rash
Hypoglycemia Irregular Heartbeat Kidney Problem
Leukemia Liver Disease Low Blood Pressure
Lung diseases Mitral Value prolapse Osteoporosis
Pain in Jaw Joints Parathyroid Disease Psychiatric Care
Radiation Treatments Recent Weight Loss Renal Dialysis
Rheumatic Fever Rheumatism Scarlet Fever
Shingles Sickle Cell Disease Sinus Trouble
Spina Bifida Stomach/Intestinal Disease Stroke
Swelling of Limbs Thyroid Disease Tonsillitis
Tuberculosis Tumors or Growths Ulcers
Allergic Reactions Sensitive Skin Venereal Disease
Yellow Jaundice
Have you ever had serious illnesses not listed?
Yes
No
Details:
Massage Information
How did you hear about us?
Have you ever had professional massage before? Yes No
How recently?
What kind of pressure do you prefer? Light Medium Firm
What type of massage are you seeking today?
Relaxation Deep Tissue/Therapeutic Pregnancy
Sports Energy Work Integrated Bodywork
Other
Are you sensitive to fragrances or perfumes? Yes No

Do you have sensitive skin? Yes No
Do you wear contact lenses? Yes No
Do you exercise regularly? Yes No

What are your common areas of pain or tension?
Please use the body diagrams to the right to indicate any areas you would like the massage therapist to concentrate on.

Treatment Authorization

The information on this page is correct to the best of my knowledge. I HAVE provided all of my known physical and medical conditions and I certify to the above statements regarding my medical condition. I understand that the services provided are for the basic purpose of relief of ailment and overall relaxation. I further understand that this message is not a substitute for medical examination, diagnosis or treatment. I authorize and give consent to receive therapy. If I experience any discomfort or pain during the session, I will immediately inform the staff.

The information on this page is correct to the best of my knowledge.
 
 
 
CLIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

Office Financial Policy

Payment is expected at time of service. We will accept cash or credit card.

 
 
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

Recieving Appointment Reminders Via Email and Text

Please check a source in which you would like to recieve appointment reminders.

Email
Text Message
Both Email and Text Message
Email Address(if applicable)
Cell Phone(if applicable)

We use this information to provide you with excellent care. We may disclose Patient Health Information (PHI) to third parties that perform services for the spa in the administration of your benefits in accordance with HIPAA. These parties are required by law to sign a contract agreeing to protect the confidentiality of your PHI. Your PHI may be disclosed to an affiliate that performs services for the spa in the administration of your benefits. Our affiliates do not sell, share or rent our users’ personally identifiable information unless required by law, do not send and e-mail or other communications without user permission, and do not send spam.

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