Male Client Consultation Form

You can now complete the Male Client Consultation Form online below and it will be submitted to me by e-mail.


Step 1 of 7
Client Confidentiality Release Form I understand that payment is due at the time of treatment unless arrangements have been made otherwise.

I agree to give at least 24 hours notice of cancellation of appointment.

Cases of extreme emergency are considered exceptions to this cancellation policy.

I understand the treatment here is not a replacement for medical care.

I understand the therapist/practitioner does not diagnose medical illness, disease or any other physical or mental conditions (unless specified under his/her professional scope of practice).

As such, the therapist/practitioner does not prescribe medical treatment of pharmaceuticals, nor does he/she perform any spinal manipulations (unless specified under his/her scope of practice).

I understand that the treatment is not a substitute for medical treatments and/or diagnosis and it is recommended that I see a qualified professional for any physical or mental conditions that I may have.

I have stated all my known conditions and take it upon myself to keep the therapist/practitioner updated on my health.
HIPAA regulations require that all practitioners should have a signed release form from their client before taking any notes about them. The best way to be fully compliant is to obtain this release signature at the initial consultation.

Practitioners should have this form signed before taking any notes. Clients should receive a copy of the form they signed (upon request) and the practitioner maintains a copy for their records.

Confidentiality of medical and personal information obtained during the course of the practitioner's work is of the utmost importance. Failure to comply with these confidentiality regulations could result in penalties.
(If you have a touch screen computer, then you can sign with your finger or a pen. For all others, use the trackpad or mouse).