Client History

Last Name:   __________________        First Name: __________________
Contact Number_______________Email_______________
Canadian Anti-Spam Legislation Consent Form
As valued clients and friends, Kawala Massage Therapy Inc. requests your consent to allow us to send you important information such as appointment reminders, clinic updates.  Your consent is required to comply with the new Anti-Spam Legislation (CASL).
You may unsubscribe by sending an email to kawalamassage@gmail.com.   If you consents please Initial ___________________
Emergency contact: _________________  Phone: _____________________

Family Physician: ___________________  Phone: _____________________

Do you presently suffer from or have you ever been diagnosed with any of the following:
                                  Yes               NO
Allergies                            ____             ____
Anemia                             ____             ____
Cancer                              ____             ____
Diabetes                             ____             ____
Heart Attack                          ____             ____
Hypertension                         ____             ____
Communicable Disease               Indicate: _____________
Osteoarthritis                         ____             ____
Osteoporosis                          ____             ____
Rheumatoid Arthritis                    ____
Stroke                               ____             ____

Other please state________________________________________
Females,  Are you pregnant?

Are you currently taking any medication prescribe or over the counter e.g. Tylenol:_____________________________________________

Massage Therapy Waiver and Consent Form

Waiver
I understand that the massage I receive is provided for the basic purpose of relaxation, stress reduction and relief of muscular tension.  I further understand that massage should not be construed as a substitute for medical examination, diagnosis or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for physical ailment that I am aware of.

I affirm that I have stated all my known medical conditions and answered all questions truthfully.  I agree to keep the therapist aware of any changes in my medical profile. I hereby release and agree to indemnify and hold harmless the massage therapist, Kawala Massage Therapy Inc. from and against any damage or injury to my person that I may directly or indirectly incur, or experience as a result of any massage therapy session that I may receive from Kawala Massage Therapy Inc. massage therapist at the Kawala Massage Therapy Inc. clinic.

I have read and understand this waiver and release and agree that the waiver and release will be binding upon me.

Date: _________________________ 

Signature: ________________________