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ReNew Life Creations Please indicate areas of tension, pain or stress you are currently experiencing on the figures below
Female Client Intake & Consent Form
Name _____________________________ Birth Date _______________ Today’s Date ___________ Address ____________________________________ City/State Zip _______________________ Home Phone ________________ Cell Phone _______________ Work Phone ___________________ Best method for confirming appointments: __ Text Cell __ E-Mail __ Phone Call __ Mail __ None In case of Emergency ____________________ Telephone _________________________________ Email ______________________________________________________________________ Have you had a professional massage? NO YES, When ____________________________________ How did you hear about us? ____________________ Occupation:_____________________________ If you have conditions requiring consultation with your doctor, please include their name and number: Physician: _________________________ Phone: _________________ Permission to contact: ______ I authorize Martin Riding of ReNew Life Creations to release medical information to person(s) named (initial here) in the event of an Emergency:_______________________________________________ Y N Have you ever received a professional Essential Oil Treatment? __ No __ Yes How recently?________________ What are your treatment goals?______________________________________________________ How much pressure do you normally prefer? Light Medium Firm Not Sure Please indicate any areas you do NOT wish to have treated: face head neck chest abdomen back breasts groin arms pelvis genitals buttocks thighs legs feet area
Mark your discomfort level on this scale: Describe discomfort:
Please check any current illness and/or medical conditions, or 1, 2 or 3 for years since occurrence: Diabetes Cancer Trouble Sleeping Frequent stress Pregnant Contact lenses Varicose veins Previous MVA/trauma Ruptured/bulging disc. Infectious conditions Recent Surgery/Accident Osteoporosis Nail or skin problems Stroke Loss of balance/Vertigo Bruise easily Sensitive to touch Heart condition Arthritis Fatigue/depression Numbness/stabbing pain Elevated cholesterol Sciatica Stress Contagious disease Seizures Autoimmune disorder Pins and needles Cardiac or circulatory Skin disorder Scoliosis Digestive problems concerns High blood pressure Frequent Headaches Painful joints Any known allergies (nuts, oils etc‌) _________________________________________________ Medications: Vitamins Herbs
Muscle Relaxants Pain Reducers Sleeping Pills
Aspirin/Antiinflammatory Steroids
Anti-anxiety/ Depressants Other
Blood thinners (coumadin, plavix, daily aspirin)
Please take a moment to carefully read the following information. If you have a specific medical condition or specific symptoms, Mild Moderate EOT may be contraindicated. A referral from your primary care provider may be required prior to service being provided. Disabling Constant When did you first notice pain or discomfort? __________ What activities are difficult/painful? __________________ Occasional Rare Chronic Recurring Duration: Constant Intermittent With certain motions How long does the discomfort last? __ min __ hrs __ days Recent New What activities are helpful? ____________ Are you currently under the care of a health practitioner? YES NO Worsening No Has there been a medical diagnosis? NO YES _______________________________________________ Improving Change What are your most frequent activities involved in work and home? sitting standing lifting other ________ What has your treatment been? _____________ In which part[s] of your body do you feel stress most often? Check all that apply. Head Neck Shoulders Feet ________________ Back Digestive Extremities Other ____________________________________________________ ________________ Previous injuries, including broken bones, NOT requiring surgery: _________________________________ ReNew Life Creations | Martin Riding | Mobile Office: 540-232-9454 | 701 8th St., Radford, VA 24141, USA. | Email: Martin@KingofOils.net | www.KingofOils.net
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ReNew Life Creations
Female Client Intake & Consent Form
INFORMED CONSENT FOR THERAPY AND/OR TREATMENT I understand that the EOT (Essential Oil Treatment) I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during the session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that EOT should not be construed as a substitute for medical examination, diagnosis, or treatment. I understand that therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because EOT should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile during the session and understand that there shall be no liability on the therapists part should I fail to do so. I understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session. I also understand that the therapist reserves the right to refuse to perform EOT on anyone whom he/she deems to have a condition for which therapy is contraindicated. I understand that any illicit or sexually suggestive remarks or advances made by me or to me will result in immediate termination of the session. Initialed consent: _____
Scope of Draping and Sensitive Areas The therapist will be working on the following areas of my body: head, neck, shoulders, back, arms, hands, legs and feet. I understand that the therapist does routine work on the chest muscles near the draped breasts. If I feel that this area is too personal for body work, I will voice my concerns. The pubic area, the genitals, breasts and the gluteal cleft are covered and are not treatment areas unless consent form is initialed here: ______ Appropriate draping will be used during each session. If I get too cool or warm, I will let my therapist know and he will adjust the draping and room temperature accordingly. Before the EOT, the therapist will ask me to remove clothing to my level of comfort. The therapist will leave the room while I undress and remove any jewelry or other articles that might interfere with the treatment. I will take off only as much as I am comfortable removing. I understand that treatment will be most effective when the Essential Oils and therapist have direct contact with my skin in areas that will be treated. After the EOT, the therapist will allow me to slowly get up and get dressed in privacy.
Overview of benefits and possible side-effects: During a treatment session the therapist may use different techniques of relaxing Aromatherapy, Essential Oil Treatment (EOT). The contraindications for EOT (when an essential oil should not be given, at least on the affected area) are: abnormal body temperature, acute infectious disease, inflammation, osteoporosis, varicose veins, blood clots, edema, untreated high blood pressure, untreated cancer, intoxication, skin problems, hernia, and some other diseases. Some temporary side effects of Essential Oil Treatment may include: • Stiffness, pain, discomfort, swelling, and/or soreness. • A sensitivity or allergy to essential oils. • Headaches (especially if not drinking enough water after an essential oil treatment) • Flu like symptoms (especially after lymphatic drainage, when metabolic waste is flushed out). • Pain or discomfort in another area of the body (sometimes by relieving the pain in the primary area, a secondary area may be getting more attention). After the treatment, it is recommended to drink more water than usual, in order to help keep the muscles and the connective tissue properly hydrated. Client’s Signature: ____________________________________________
Date: _____ / _____ / _____
Consent to Treatment of Minor: By my signature below, I hereby authorize Martin Riding, ReNewLife Creations, to administer Essential Oil Treatment or Aromatherapy techniques to my child or dependent as they deem necessary. Signature of Parent or Guardian _____________________________ Date ___________________________ ReNew Life Creations | Martin Riding | Mobile Office: 540-232-9454 | 701 8th St., Radford, VA 24141, USA. | Email: Martin@KingofOils.net | www.KingofOils.net
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ReNew Life Creations
Female Client Intake & Consent Form
INFORMED CONSENT FOR OIL THERAPY WITH HOT STONES I hereby request and consent to the performance of hot stone therapy on me [or the client named, for whom I am legally responsible] by any therapist. I understand that hot stone therapy involves heating stones, using those stones during the course of therapy, either by the therapist placing those stone on me to warm and relax muscles, or by the therapist holding those stones in their hands and then massaging me with those stones. I understand that: 1. Therapeutic oil is a generally safe method of treatment, but that it may have some side effects, including burns or related scarring as a result of the contact of the hot stones with my skin. 2. A variety of medical conditions which I might have, and which my therapist has neither the training, nor the legal right to interpret, could increase the risk of burns for me. 3. The sensitivity of my skin type may also impact the risk associated with burns and scarring. 4. Certain medications make a person more sensitive to heat exposure. I do not expect the therapist to be able to anticipate and explain all possible risks and complications of hot stone therapy. I wish to rely on the therapist to exercise judgment during the course of the hot stone therapy, which at the time, based upon the facts then known, is in my best interest. I understand that the results are not guaranteed. Client Signature _________________________________________________ Date ____________________________ Practitioner Signature ______________________________________________ Date ____________________________
INFORMED CONSENT FOR LYMPH GLAND DRAINAGE Under NRS 640C.700(4)(c) Grounds for disciplinary action include massaging, touching or applying any instrument to the breasts of the person unless the person has signed a written consent form provided by the Board. When the treatment of sensitive areas is indicated during the course of a Essential Oil Treatment/therapy, it is important that you, the client, fully understand the nature and purpose of this treatment. In addition to our discussion about the treatment, this written consent form will act as a record of that discussion. If you have any questions, either during our discussion or while completing this form, please do not hesitate to ask.
There are various levels of comfort in receiving body and/or breast lymph drainage. My  initial area of concern for lymph gland drainage is: ________________________________________________________________________________________ Please note that lymph drainage can be done for whole body to remove toxins or parts of the body (i.e. Arms, legs, torso, head, breasts, groin, chest etc. To be effective in the removal of the toxins it means that there are no constrictions on the body – bras, underwear, tight clothing, socks, jewelery etc., which can inhibit the toxin removal. The process is done with very light pressure and in the case of blocked glands hot towels may also be used to ease the toxin removal. The process can be done under draping or uncovered according to your preference. If draped you will be kept covered except the areas to be worked or the work can be done under the drape which will take longer to apply the oils. Please indicate your preference below as to how you would like for the lymph gland drainage to proceed with your level of comfort.
I am initialing the statements that I feel comfortable with: ____ I would like the therapist to demonstrate the lymph drainage while clothed. ____ I would like to remain draped and have the therapist work with me under the draping. ____ I am comfortable having the therapist work on the uncovered portion of body while performing lymph drainage. For breast lymph gland drainage. (The nipples will not be touched.) ____ I am comfortable having the therapist work under the draping while working on the breasts. ____ I am comfortable having the therapist work directly on the uncovered breasts. After the session you may notice a taste of aluminum or chemical taste as the toxins are passed from your body especially after the breast lymph gland drainage. This can last from a few minutes to a few hours and is normal. It is important to drink several glasses of water after a session for the next few days. The need to urinate more than usual to pass toxins is also normal.
I understand that I can alter or withdraw my consent for this treatment and/or treatment plan at any time during this or any other treatment. Please retain this record as instructed under NRS 629.051
Client Signature _________________________________________________ Date ____________________________ Practitioner Signature ______________________________________________ Date ____________________________ ReNew Life Creations | Martin Riding | Mobile Office: 540-232-9454 | 701 8th St., Radford, VA 24141, USA. | Email: Martin@KingofOils.net | www.KingofOils.net