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Informed Consent

(Please read to sign at appointment)

                                     INFORMED CONSENT

The operations at this location:

Services include the medical skills that involve the practice observing and palpation of the skin. The treatments are superficial and noninvasive. The treatments are done only with gentle soft hand touch. There are no deep tissue treatments offered.  The treatments are not meant to do harm, cause pain or discomfort, but are meant to promote relaxation to help improve physical health and well-being.  The treatments do not include deep tissue treatment with the use elbows, knees, feet, needles or balls. This location does not offer massage therapy, physical therapy or behavior therapy.  It does not offer cosmetic surgery, body work enhancement procedures, surgical removal of tissue, injury repair, antiaging procedures or pain management. There are no pharmaceutical medicines on site.  If further treatments are needed beyond the scope of care within this location, as a primary care board certified physician, Dr. Organ is licensed to  recognize urgent concerns and make recommendations or referral to the appropriate therapist or specialist as needed.

I have read the above information. I fully understand and agree to services on these terms. It is my choice to receive Touch treatments. I am aware of the benefits and risks of the treatments and give my consent.  I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that touch treatment is not a substitute for medical care, medical examination, or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status. I understand that my personal health information will be collected. I understand that all information that I provide will be kept confidential unless required by law. I understand and consent that my medical information may be shared by the various care providers involved in my care and treatment.


Name (Print)____________________________________________



Menstrual and Medical History

(Please review we will fill out and sign at appointment)

  Dr. Mirian Boyd Organ’s Women’s Day Spa

  History form

    Name _________________________________________________


   Address _______________________________________________

   City ______________________________________State __________

   Zip _____________________________ Phone____________________________

   Email ____________________________________________________________

Menstrual History (Complete as much as you can even if you are menopausal)

Age ______________   Preg___ Live biriths____         LMP_____________

Age periods started_______________  Breastfeeding history: yes or no

If your menstrual periods are regular ____________, How many days apart_____

If your menstrual periods are irregular__________, How many times a month___

How heavy is your bleeding, ____mild _____moderate______heavy (clots)

Which symptoms are associated with your periods, (before, during or after) 

     ___anger                   ____depression         ____loss of interest

     ___anxiety                 ____headaches        ____self-depreciating thoughts

     ____clotting              _____hot flashes           ___Sensitive to rejection

     ____cramping            ____heart palpitations     ___difficulty concentrating

     ____cravings              _____irritability                    ___leg swelling

     ____crying                  ____insomnia                      ____Binge eating

     ____bloating              ____Fatigue or exhaustion ____Brain fog

     ____bowel changes    ____mood swings                ____Rage

     ____Breast tenderness  ___less productive        _____Panic attacks     

    ___Back ache ____Nause/vomiting  _ ___Family is concerned _____acne

    ____Overthinking   ____ Overtalking     _____more sensitive

     Gynecological/ obstetric surgery:

         Ovaries:  yes ______               no________

         Uterus:      yes _____              No________

         Fallopian tubes:   yes_______     No_______

         Cesarean Section:  yes______     No_______

         Abdominal surgery:  yes______   No______

          Breast Surgery: yes_______         No_______


   Hospitalizations in the last 5 years___________________________________

Allergies________________      Occupation______________________________


Heart Dx _____      Diabetes ________    High Blood Pressure____ Strokes _____

Cancer(type)_______  Neuropathy______ Kidney Dx_______

Gastrointestinal Dx_______ Arthritis______ Anemia______

Musculoskeletal ______Seizures______ Asthma_______Thyroid DX_______

HIV/Aids_______Smoking______Alcohol_______Illicit Drugs_________

Obesity_______, Eating Disorder_______ Mental Health_________

Depression and Anxiety________ Family loss_______

Financial loss_______ other____________________________


Do you take your regular prescribed medicines?  Yes_______  No______

Last Primary Care Physician visit________________

Signature____________________________________ Date_______________

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