Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

YYYY

Phone Number

Occupation

Who is your General Medical Practitioner?

Please provide Dr. name and surgery phone number.

Surgery

Have you ever had surgery for any of the above conditions?

Do you suffer with TMJ Dysfunction?

YES

UNSURE

Jaw pain symptoms

Please tick any of these jaw pain symptoms you are currently experiencing.

Jaw clicking

Jaw locks open

Jaw locks closed

Jaw popping

Teeth Clenching

Teeth Grinding

Pain Indicator

On a scale of 1-10 what would you say your current pain level is?

Are you taking any medication?

If Yes, please list here:

Are you happy to receive Intra-Oral Pterygoid Techniques?

YES

Are you pregnant?

YES

Are you allergic to latex?

YES

How did you hear about TMJ Massage Therapies?

Massage Therapy Informed Consent Form

This record of consent is required before the first assessment or treatment and will be maintained confidentially in the client file. It may only be released to a third party with prior or written consent of the client. Massage Therapy includes the assessment and treatment of the soft tissues and joints of the body using soft tissue manipulation, joint mobilization, remedial exercises and self-care programs as determined by the therapist. Treatment plans will be discussed with the client prior to the start of treatment. By signing below, the client agrees with the following: • Written consent must be given by me prior to any disclosure or sharing of my personal and clinical information with any third party. • All massage treatments, information and records will be kept confidential and securely stored for use only by massage therapist. • The information I have provided on the attached client detail form is true and correct. • Privacy will be assured as I have the right to undress only to my comfort level and according to the requirements of the treatment. • Draping will be used by the therapist as required to expose only those parts of my body that require treatment and/or as I choose to ensure my comfort during treatment. • If at any time during the treatment I feel uncomfortable with the treatment for any reason, I have the right to request an immediate stop to the session or request modification to the treatment, regardless of prior consent given. • Promptness is expected for all appointments. In the event of lateness, the massage may be cut short due to other commitments of the therapist. Fees will be maintained per the schedule. • Cancellation of any appointment must be received at least 24 hours in advance otherwise 50% of the appointment fee is due. • Fees for treatment are due prior to departure on the day of treatment. Cash, EFT & Credit Cards are accepted. • The therapist may refuse to treat any client or part of their body with just and reasonable cause. Have you read and understood the information above and consent to the massage treatment for the condition discussed with your therapist today?

YES

GDPR Client Consent Form

We will process any Personal Data you provide to us for the following purposes:(i) to provide you with the services you have requested;(ii) to contact you if required, in connection with your request, or to respond to any communications you might send to us;(iii) to send you newsletter, event alerts, information about product releases, service notifications and to communicate with you about relevant industry information and activities. This is only pertinent if you voluntarily sign up for this service. For the purposes of providing this On-line Consultation, Helen Baker at TMJ Massage Therapies may require detailed medical information. She will only collect what is relevant and necessary for your treatment plan. During the consultation Helen Baker will make notes that may include details concerning your medication, treatment and other issues affecting your health. This data is always held securely, is not shared with anyone not involved in your treatment. To be able to process your personal data it is a condition of any treatment that you give your explicit consent to allow the Practitioner, Helen Baker to document and process your personal medical data. Contact details provided by you such as telephone numbers, email addresses, postal addresses may be used to remind you of consultation details, future appointments and provide reports or other information concerning your consultation or treatment plan. Do you agree?

YES

COVID-19 Consent Form

Are you aware that you may need to complete a COVID-19 Health Screen Consent Form and have your temperature taken before treatment?

YES

Thank you so much for completing this form. If you have any further questions please do not hesitate to contact me otherwise I look forward to meeting you soon and helping you with your jaw pain!

Many thanks, Helen @ TMJ Massage Therapies