Holistic Health Services

Second opinion consultation and treatment consent

I, the undersigned, hereby give voluntary consent for the administration of treatment by the methods of holistic medicine.

I understand that health and illness according to holistic medicine is different from that accepted by Western medicine.

I understand that there are no guarantees with Holistic medicine, and I volunteer to receive treatment.

I understand that the professional herbal supplements recommended and/or given to me as remedies are provided for my use in a manner delineated by the American Herbal Pharmacopoeia. http://www.herbal-ahp.org/

I understand that I have not by any of the foregoing provisions agreed to cease or not pursue any conventional or non-conventional medical treatment and may continue with any other such treatment and/or seek any other professional medical opinions or treatments that I choose.

I understand that the treatments recommended at this office are not a substitute for treatments and health maintenance recommended by my physician.

I affirm that I have stated all my medical conditions and medications.  I agree to indemnify, and hold harmless Holistic Health Services and Therapist(s) from and against any and all claims, demands, loss or liability of every nature, for injuries to person and/or property, occurring in or about or in any way connected with Spa Therapy Wellness Center.

I agree to keep Holistic Health Services updated in the event that my medical condition changes.

If I fail to keep an appointment by neglecting to cancel my appointment within 24 hours, I will pay Holistic Health Services 100% of the fee for the missed appointment.  I acknowledge that I am ultimately responsible for payment.  I am of lawful age and have read and fully understand the contents of this document and the complete terms and conditions herein.  This agreement contains the complete agreement between parties and no other guarantees or refunds will be given on products or services.

Package Choices are:

Check the box of the package you will be purchasing.

□ single session at $180/ea     □ 5 sessions at $160/ea   □ 10 sessions at $150/ea

In an effort to advance the discipline of holistic health, improve our services, and increase our knowledge, we occasionally videotape sessions.  If you do not which to participate, please check this box □.

I hereby certify by my signature that I have read this entire form, that I understand all its provisions, that I have discussed any question to my satisfaction.  I have answered all the questions honestly.

Signature_________________________                Date____________________________

________________________________               ________________________________

Name (please print clearly)                                              Guardian (if under 18 years old)

CLIENT INFORMATION FORM

Name: __________________                             Date of Birth: ___________

Telephone: (        ) -         -

Address: ______________________________________________________

e-mail address: ______________________________________________________

State: __________________          Zip: ___________    City: __________________

Telephone: (        ) -         -

Telephone: (        ) -         -

Referred by: ________________________  Telephone: (        ) -         -

In case of emergency: ___________________      Telephone: (        ) -         -

General & Medical Information

Occupation: :______________       Age: __          male__         female__

Physician:______________

Health Insurance Carrier:

___________________________________________________________

Holder Name:______________________________      ID #: __________________

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/physical exercise may be contraindicated. A referral from your primary care provider may be required prior to service being provided.

Have you ever experienced a professional massage, bodywork session, or physical exersice session? ___ Yes                            ___ No

How recently?     _____________________

If you answer yes to any of the following questions, please explain as clearly as possible.

• __ Yes   __ No:         Do you frequently suffer from stress?
• __ Yes   __ No:         Do you have diabetes?
• __ Yes   __ No:         Do you experience frequent headaches?
• __ Yes   __ No:         Are you pregnant?
• __ Yes   __ No:         Do you suffer from arthritis?
• __ Yes   __ No:         Do you wear contact lenses?
• __ Yes   __ No:         Do you wear dentures?
• __ Yes   __ No:         Do you have high blood pressure?
• __ Yes   __ No:         If yes to previous question, are you taking medication
•                                  for this?
• __ Yes   __ No:         Do you suffer from epilepsy or seizures?
• __ Yes   __ No:         Do you suffer from joint swelling?
• __ Yes   __ No:         Do you have varicose veins?
• __ Yes   __ No:         Do you have any contagious diseases?
• __ Yes   __ No:         Do you have osteoporosis?
• __ Yes   __ No:         Do you have any allergies?
• __ Yes   __ No:         Do you bruise easily?
• __ Yes   __ No:         Have you had any broken bones in the past two years?
• __ Yes   __ No:         Have you been in an accident or suffered any injuries
•                                   in the past two years?
• __ Yes   __ No:        Do you have tension or soreness in a specific area? Please specify:__________________________________________________________

• __ Yes   __ No:        Do you have cardiac or circulatory problems?
• __ Yes   __ No:        Do you suffer from back pain?
• __ Yes   __ No:        Do you have numbness or stabbing pain anywhere?
• __ Yes   __ No:        Are you very sensitive to touch or pressure in any area?
• __ Yes   __ No:        Have you ever had surgery? Explain below.
• __ Yes   __ No:        Do you have any other medical condition or are you  taking any medications I should know about?

Comments: _______________________________________________________________________

_______________________________________________________________________

Details:

MEDICATION/VITAMINS/OTHERS                   DOSAGE                          PURPOSE _______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

Client Signature ______________________          Date _________

Consent to Treatment of Minor:

By my signature below, I hereby authorize HOLISTIC HEALTH SERVICES PROFESSIONALS to administer massage, bodywork or somatic therapy techniques to my child or dependent as they deem necessary.