Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Primary Phone Number
*
Usually a cell or home phone number.
(###)
###
####
Email Address
*
Date of Birth
*
MM
DD
YYYY
Gender
*
Please note that if you are using insurance for your visit that your gender needs to match what your insurance provider has on file.
Emergency Contact Name
*
First Name
Last Name
Relationship
*
Spouse
Parent
Sibling
Child
Friend
Other
Emergency Contact Phone Number
*
(###)
###
####
Employer
Occupation
Health Insurance ID#
Reason for visit/Treatment goal(s)
What areas would you MOST like to focus on?
Are there any areas you would like us to AVOID?
List any physical activities you are involved in and the frequency you participate in them
Please state any past or present injuries, accidents or medical treatments
Medical Conditions
Please check any of the following conditions you have or have recently had:
Medical Conditions cont'd
Please include any further details or other conditions you would like to share here:
If you are currently under the care of a physician
Please state their name and list the reason(s)
Please list any medication taken now or at regular intervals
Attestation
*
The above information is true and accurate to the best of my knowledge. Any information provided is for safety purposes and will be kept strictly confidential. I will update my therapist on any changes that occur with my physical or mental health.
Massage Therapists do not diagnose any medical, physical or emotional disorder, prescribe medications or manipulate bones. Massage therapy is not a substitute for medical attention, examination or diagnosis.
If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure or stroke can be adjusted. I will not hold my therapist responsible for any pain or discomfort I experience during or after the session. Massage therapy is a therapeutic health aid and any sexual remarks or advances will terminate the session, and I will be liable for payment of the scheduled session. It is my choice to receive massage therapy and I give consent to receive treatment.
If I use my health insurance for services and my insurance company denies payment, I agree to be personally and fully responsible for payment. I also understand that if my health insurance company does make payment for services, I will be responsible for any co-payment, deductible or coinsurance that applies. I am aware that most plans will only cover up to 1 hour per day and I will be responsible for the difference if my appointment exceeds 1 hour. I understand it is my responsibility to know my health coverage, that I am responsible for keeping track of visit usage and denials due to benefit exhaustion are my responsibility. The Garage Massage Therapy has a cancellation/no-show policy requiring 24 hours’ notice. This fee is compensation for the therapist if that appointment is unable to be filled. If I cancel my appointment within 24 hours, I agree to pay the $60/hr cancellation fee for the service I missed. If I miss my appointment without any notice, I agree to pay $100/hr for the missed service.
Electronic Signature
*
First Name
Last Name
Date Signed
*
MM
DD
YYYY
