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    For ALL IN-CLINIC Patients, It is required to fill out this screening questionnaire for EACH VISIT to the clinic

    Conscent Form
    1. Devorah Eisenman BHK, RMTSusan Patterson, RMTTien Dao, RMTOther

    2. I have requested assessment and/or treatment by the above Registered Massage Therapist (RMT) for treatment of the clinically relevant areas indicated below (please select ):
    3. The RMT has explained the following to me and I fully understand the proposed assessment and/or treatment: • The nature of the assessment, including the clinical reason(s) for assessment of the above areas(s) and the draping methods to be used • The expected benefits of the assessment • The potential risks of the assessment • The potential side effects of the assessment • That consent is voluntary • That I can withdraw or alter my consent at any time I voluntarily give my informed consent for the assessment and/or treatment as discussed and outlined above.

    Declaration:

    I have answered all the above questions honestly and truthfully

    Signature

    * Required