Patient Intake Form Therapeutic Touch Massage (Page 2 of 2) in pdf

Patient Intake Form Therapeutic Touch Massage Page 2

Please explain any of the above conditions, when were you diagnosed and what is

your current status?

______________________________________________________________________

What are you looking for in your treatment today and ongoing treatments?

________________________________________________________________________

Are you currently under the care of a doctor, chiropractor, PT?

Yes___

No___

If so, please explain_______________________________________________________

Do you exercise? Yes___

No___

If so please list what you are doing currently.

________________________________________________________________________

I understand that I am receiving treatment/s under my consent and that my

massage therapist will treat me according to my medical condition/s and by any

regulations that my doctor, chiropractor, or physical therapist has prescribed. All of

the information I have provided involving any and all medical conditions are

current, and if at any time these conditions change I will inform my massage

therapist of these changes.

If at any time there is any inappropriate behavior I understand that I am

responsible for full payment of the time and will not be allowed back on the

premises. If I arrive late for an appointment I understand that I will be treated in

the remaining time available for that particular time. I understand that no shows

and last minute cancellations will result in full charge of the session I missed.

Signature_______________________________ Date________________

Printed name_________________________________________________

Therapeutic Touch Massage, LLC 9/01/2014

Patient Intake Form Therapeutic Touch Massage Page 2