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Terms & Conditions:
Client Agreement
It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy 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 the american massage therapy association® has provided this form as a reference and is not held liable for any services provided.
Assignment of Benefits
I am responsible for all charges for all service provided. In the unfortunate event that my insurance company denies payment, or makes a partial payment, I am responsible for any balance due. If you, my massage therapist, have contracted with my insurance company at a discount rate for services, the amount remaining will be waived and I will not be asked to pay the balance.
Release of Medical Records
I authorize the release of medical records or other health care information, including intake forms, chart notes, reports, correspondence, billing statements, and other written information to my attorneys, healthcare providers, and insurance case managers, for the purposes of processing my claims.
(Please inform your practitioner immediately upon signing any exclusive Release of Medical Records with your attorney that may impact the above release statement.)
Contract for Care
I will participate fully as a member of my healthcare team. I will make sound choices regarding my sessions? plan based upon the information provided by my massage therapist. I agree to participate in my own self-care programs and adhere to the plan we select. I agree to communicate with my practitioner any time I feel my well-being is being compromised. I expect my practitioner to provide safe and effective treatment to the best of his or her skills and knowledge.
Signature of parent or legal guardian required if client if is a minor - please call for more information.
I acknowledge that my therapist has given me an appointment time which will be exclusively reserved for me. Failure to provide 24 hours notice of cancelation may result in my account being charged for the therapist time.
I authorize and direct payment of medical benefits to my massage therapist, for services billed.
Initial here to acknowledge you have read & understand all the above terms & conditions:
Intake Form:
First Name:
Street:
Last Name:
City:
Email:
State:
Home Phone:
Zip:
Work Phone:
Date of Birth:
Cell Phone:
Employer:
Job Title/
Description:
Injuries:
Medical Conditions:
What do you hope to gain from massage?
How often have you received professional massage therapy?
What areas do you hold most of your stress?
What repetitive motions do you preform at work or in athletics?
May we confer with your other health professionals? Is so, please list their names and numbers:
What type(s) of massage do you know you like (or not care for)?
Is there anything else you would like to share?
To send, click the "Submit" button once.
Home
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Additional Info
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Whole Health Massage
