Massage Therapy Patient Intake Form - Advanced Spinal Care Page 2
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1
2Do you have a pacemaker?
Yes
No If yes, please alert our chiropractic assistant
Please list any other electrical device that you currently wear__________________________________________________
Do you smoke
Yes
No ___pack/day/wk Do you drink alcohol
Yes
No ____oz/day/wk
Have you ever had massage therapy
Yes
No If yes, last date of treatment____________________________________
What are your overall expectations from your treatment with our massage therapist (s)
____________________________________________________________________________________________________
It is my choice to receive massage therapy and I give my consent to receive treatment. I understand that a massage
therapist cannot diagnose illness, disease or any other medical, mental or emotional disorder nor do they prescribe
medical treatment, pharmaceuticals or perform spinal manipulations.
WOMEN ONLY I hereby declare that to the best of my knowledge,
I am
I am not pregnant.
CONSENT TO TREAT A MINOR: I hereby authorize and give consent for the Massage Therapist at Advanced Spinal Care
to treat my minor child through massage therapy ________________________________ (Please Print Minor’s Name)
Patient Signature_________________________________________ (Parent/Guardian signature if under 18 years of age)
GENERAL/FINANCIAL POLICY
Welcome to Advanced Spinal Care of Lakeland. We strive to provide you with excellent Chiropractic care in a clean, friendly,
professional setting and our goal is to make your visits as convenient as possible.
By signing below, you confirm that you have read this policy and understand that:
It is your responsibility to inform our office of any address or telephone number changes.
Your account is to be kept current. All self pay or insurance copayments, co-insurances and deductibles will be collected at
the time of service payable by cash, check, Visa, MasterCard, Discover, American Express or Care Credit.
If you do not have your payment (s), your appointment may be rescheduled.
If you are unable to keep a scheduled appointment, please notify us no later than the day before so that we may offer that
time to another patient. There is a $25.00 charge for missing a half hour massage appointment and a $50.00 charge for
missing a full hour massage appointment without proper notification. Hour massage appointments will be booked with
a credit card on file.
A returned check will result in a $25.00 service charge and all future payments being required in the form of cash or credit
card.
You will only be sent a statement if your balance exceeds $5.00.
If your account is turned over to a collection agency, you will be responsible for any costs incurred in collection of said
balance, which may include collection agency fees up to 35% of your outstanding balance, court costs and attorney fees.
We realize that temporary financial problems may affect timely payment of your account. If such problems do arise, we urge you to
contact us promptly for assistance in the management of your account. If you have any questions about the above information,
please do not hesitate to ask us. WE ARE HERE TO HELP YOU.
By signing below, you have read and understand the above Financial Policy and agree to meet all financial obligations.
_______________________________
_____________________________________
_____________
Printed Name
Signature of Patient/Legal Guardian
Date
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