Client Intake Form Page 2
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2client agreement & health release form
insurance information
client agreement
It is my choice to receive massage therapy. I am aware of the benefits and
client’s full name
date
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
ins. ID #
date of injury
techniques or series of appointments. I acknowledge that massage therapy
is not a substitute for medical care, medical examination or diagnosis. I have
Is your condition the result of an auto accident?
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Yes
No
stated all medical conditions that I am aware of and will inform my practitioner
If so, in what state did the accident occur?
of any changes in my health status. I understand that the american massage
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therapy association® has provided this form as a reference and is not held
A work injury?
A health condition?
Other
liable for any services provided.
What type of insurance do you have that may cover you for this
signature
date
condition?
(check all that apply)
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Auto
Workers’ compensation/state Industrial
Liability
Health
assignment of benefits
Was a police/accident report filed?
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Yes
No
Client’s relation to insured?
I am responsible for all charges for all service provided. In the unfortunate
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Self
Spouse
Partner
Child
Other
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
insured’s full name
contracted with my insurance company at a discount rate for services, the
ins. IS #
amount remaining will be waived and I will not be asked to pay the balance.
date of birth
I authorize and direct payment of medical benefits to my massage therapist,
for services billed.
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Male
Female
Single
Married
Partnered
Other
signature
date
address
signature of parent or legal guardian (if client if a minor)
city
state
zip
home phone
cell phone
release of medical records
work phone
I authorize the release of medical records or other health care information,
employer’s name/school name
including intake forms, chart notes, reports, correspondence, billing statements,
and other written information to my attorneys, healthcare providers, and
address
phone
insurance case managers, for the purposes of processing my claims.
primary insurance plan name
signature
date
group number
plan number
signature of parent or legal guardian (if client if a minor)
phone
(
Please inform your practitioner immediately upon signing any exclusive Release of
plan’s billing address
Medical Records with your attorney that may impact the above release statement.
)
city
state
zip
contract for care
secondary insurance information
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
who is your attending physician?
name
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
address
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
city
state
zip
knowledge.
office phone
fax
I authorize and direct payment of medical benefits to my massage therapist,
Permission to consult with
regarding
Your initials
____________
____________
____________
for services billed.
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Has an attorney been retained?
Yes
No
signature
date
name
signature of parent or legal guardian (if client if a minor)
address
city
state
zip
home phone
work phone
This form was created as a resource by the american massage therapy association®
and they are not held liable for any services provided.
fax
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