Application for Therapy

Preventative Healthcare/Healthcare Management

Please list all stress reduction and exercise activities (include frequency).

Please list current medications (prescription or over the counter).

Present and Previous Issues

List all surgeries/medical procedures (include year).

List all accidents (include year).

Please indicate if you have ever had any of the following:

What stage of pregnancy are you?

Please indicate if you have ever had any of the following:

Please note any pathology past or present not listed above:

I have chosen to receive bodywork therapy from Karina Rhode (i.e. “Practitioner”). I realize that treatment I receive is for the well being of my body and mind. This may include stress reduction, relief of muscular tension, spasm and pain, increased circulation or energy flow. I agree to communicate with my practitioner any time I feel that my well-being is being compromised. I understand that Practitioner will not diagnose illness, disease, physical or mental disorder. Practitioner will not prescribe medical treatment, pharmaceuticals, or perform deliberate skeletal/spinal adjustments. I acknowledge that bodywork is not a substitute for medical examination or diagnosis, and that it is recommended that I see a primary health care provider for that service. I acknowledge that Practioner’s treatment is a non-sexual service. Practitioner may terminate session as a result of sexual advances, behavior, or comments and I will still be responsible for full payment of the session. I have stated all medical conditions that I am aware of and will update Practitioner of any changes in my health status. I acknowledge that my health history and personal information records are confidential. My therapist will not release these records to any party without my consent. I hereby release approval and consent by indicating my name and date below. Upon clicking the submit button below, I authorize Bodyworx by Karina to use and process this information for use in treatment. I understand that this information is confidential and will not be shared with third parties without my consent. *

Yes, I agree.

Client Name *

Date / Time

Book an Appointment

Application for Therapy

Massage and Treatment History

Consent for General Treatment

Request & Consent for Treatment of Breast Tissue

Preventative Healthcare/Healthcare Management

Present and Previous Issues

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