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For ALL IN-CLINIC Patients, It is required to fill out this screening questionnaire for EACH VISIT to the clinic
Name*
Email (if you want a copy)
Date of Birth *
Which Therapist Are You Seeing Today?* Devorah Eisenman BHK, RMTSusan Patterson, RMTTien Dao, RMT
Which therapist will you be attending? Devorah Eisenman BHK, RMTSusan Patterson, RMTTien Dao, RMTOther
*
How did find out about this event? Buttocks (gluteal Muscles)Chest Wall MusclesUpper Inner Thigh (s)
Client Name/Guardian:
Declaration:
I have answered all the above questions honestly and truthfully
Signature
* Required
