"*" indicates required fields Step 1 of 4 25% Personal InformationName* First Last Date of Birth* Month Day Year Address* Street Address Address Line 2 City Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Phone*Email* Occupation*e.g.: Desk Job, Physical Labour, Driving, Other Massage HistoryHow often do you receive professional massage? This is my first massage Once or twice a year About once a month A few times a month Once a week or more What types of physical activities do you engage in? Current Health InformationList any medications you use, including over-the-counter-drugs:List any surgeries, including year and treatment:List any accidents currently affecting your health:Select any conditions currently affecting your health Allergies Arthritis Asthma/Breathing Difficulty Athlete’s Foot Autoimmune Disease Blood Clots Low/High Blood Pressure Bone/Joint Disease Broken Bones Bronchitis Bursitis Cancer/Tumors Chronic Fatigue Syndrome Constipation Crohn's Disease Depression Diabetes Diverticulitis Epilepsy/Seizures Fibromyalgia Head Aches/Injuries Heart Condition Infectious Disease Irritable Bowel Syndrome Jaw Pain/TMJ Low Back/Hip/Leg pain Lymphedema Multiple Sclerosis Neck/Shoulder/Arm pain Numbness/Tingling Parkinsons Pregnancy Rashes Sinus Problems Sleep Disorders Sprains/Strains Tendonitis Varicose Veins Pregnancy Due Date Month Day Year Additional information about your conditions Disclosures I have read, understood, and agree to the below statements regarding the services provided at Muscle Matters.It is my choice to receive massage therapy. I realize that the treatment is being given for the well-being of my body and mind. This includes stress reduction, relief from muscle tension, spasm or pain, or for increasing blood and lymphatic circulation. I agree to communicate with my therapist any time I feel my well-being is being compromised. I understand that massage therapists do not diagnose any physical or mental illness, disease, or disorders. I further acknowledge that massage therapy is not a substitute for medical examination or diagnosis, and that it is recommended that I see a physician for that service. I have stated all medical conditions to the best of my knowledge and will make the massage therapist aware of any changes in my health.Policies I have read, understood, and agree to the policies at Muscle Matters.Cancellation Policy At least six operating hours notice are required to reschedule or cancel an appointment. You will be charged 50% of the cost of your appointment if you do not provide a minimum of six business hours notice when you change or cancel your appointment. If you can’t make it to your appointment, you can send someone else in your place to avoid being charged the cancellation fee. Advanced Therapies Some conditions may not be suitable for advanced therapies. Please talk to your RMT to ensure your safety with the use of Cupping Massage or Hot Stone Massage. As with all massage treatments, it is essential that you communicate with the RMT during your cupping massage to provide feedback regarding pressure level, pain, or any discomfort that you feel. This feedback guides the RMT into providing a safe and comfortable treatment customized to your needs. Use of Email Address From time-to-time, Muscle Matters may contact you at the email address you’ve provided. We may use your email address to contact you for feedback purposes, to provide information about your appointment, or to conduct other clinic business. At no time will we lend, sell, or give away your email address to a third-party. You are providing your email address to Muscle Matters only. We operate an email newsletter to advise you of clinic news or promotions. If you decide that you would not like to receive the email newsletter, you may unsubscribe easily using the link provided in the newsletter. Unsubscribing is immediate, and you will not receive any further email newsletters from us.CommentsThis field is for validation purposes and should be left unchanged. Δ
