Function Manual Therapy Intake Form

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Personal Info
Contact Info
Emergency Contact
Doctor
Appointments and Communication
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Manual Therapy History
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What are you looking to achieve with Manual Therapy? (Check All That Apply)

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All information is strictly confidential and will only be released with a signed consent form per HIPAA guidelines - Kindly fill out information as thoroughly and with the most reliable contact information as possible.  If taking medication(s), please try to include dosages and frequency, if injury(ies) or surgery(ies), try to include dates. 

Medical Conditions
Area of Complaint
Headaches
Neurological
Cardiovascular
Reproductive
Immune
Musculoskeletal
Gastrointestinal
Blood
Skin
Respiratory
Hearing
Kidney
Endocrine
Family History
Miscellaneous
Medications
Injuries
Surgeries

Acknowledgement Statement, Policies and Consent of Treatment

This is to inform clients of their responsibility regarding their health and medical conditions which should be disclosed properly to the massage therapist.

 

Please notify us at anytime if: 

  • Room temperature is too cold or warm. 

  • If you feel faint or ill. 

  • The music is not to your liking, or too loud or soft. 

  • The pressure/touch is too deep or not deep enough. 

  • You would like to stop the session. 

  • You would like additional manual therapy in a particular area that needs attention. 

 

The following are normal responses to relaxation that may sometimes occur during massage: 

  • You need to move or change position.

  • Sighing, yawning, change in breathing.

  • Stomach gurgling (or release of internal gas).

  • Emotional feelings and/or expression.

  • Falling asleep.

  • Memories of past accidents or trauma.

 

Rules and Policies to help make your massage more pleasurable: 

  • Please notify this office 24 hours in advance of any cancellation of your appointment.

  • Promptly notify us of any injuries or changes in your health issues when making your appointment.

  • Any client under the age of 18 must be accompanied by a parent or legal guardian.

  • All notes, questionnaires, conversations, and client information will be kept strictly confidential.

  • We encourage you to shower or wash for hygienic reasons prior to your massage.

  • Your privacy will be respected at all times with proper draping. Please help us maintain propriety during your massage.

  • Please refrain from wearing perfumes or jewelry when coming for a massage.

  • Please do not smoke / vape on premises, please do not smell of smoke prior to your massage.

  • Please turn off mobile device alarms inside the office or treatment room.

  • Payment is due at the time of the massage unless other arrangements have been made in advance.

 

Cancellation Policy

We understand that unanticipated events happen occasionally in everyone’s life. In our desire to be effective and fair to all clients, the following policies are honored:

 

We ask that you notify us at least 24 hours prior to your appointment time 

if you need to cancel. This allows us to offer time to others who are in need of treatment. Failure to notify resulting in a no show will adhere to the following fee schedule:

 

No Shows/Cancellations within 24 hours:

  • First Offense: 50% charge. This amount must be paid prior to your next scheduled appointment.

  • Second Offense: 75% charge

  • Third Offense: 100% charge and discontinuation of service.

  • Thank you for understanding.

 

Late Arrivals:

If you arrive late, your session may be shortened in order to accommodate others whose appointments follow yours. Depending upon how late you arrive, your therapist will then determine if there is enough time remaining to start a treatment. Regardless of the length of the treatment actually given, you will be responsible for the “full” session. Out of respect and consideration to your therapist and other customers, please plan accordingly and be on time.

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