Therapeutic massage client intake form the information request below assists us in treating you safely. The following information will be used to help plan safe and effective massage sessions. Zen shiatsu therapy intake form all information is kept strictly confidential informed consent to shiatsu therapy it is my choice to receive shiatsu therapy. Coronavirus intake form for massage therapy form template. Because massage may be contraindicated for specific medical conditions, i hereby release the massage therapist from. There is also a link below to download a pdf version of our intake form which can be printed out, filled. I just want to say, ive benefitted from your open, honest and nononsense approach to running a massage practice. Therapeutic massage and manual lymphatic drainage intake.
Name of person completing form if other than patient. We support a wide range of question formats, including body diagrams. I, being the authorized agent or owner of this horse, have read and understand the information on this form. Recommended best practices for massage therapy the following requirements found in the most recently issued directed health measures dhm must be followed at all times if a massage therapy facility is to reopen. Massage client intake form general and medical information. I further understand that massage or bodywork should not be construed as a substitute for medical examina tion, diagnosis, or treatment and that i should see a. Generally, therapists require patients to fill out the massage intake form before their appointment. This is the reason why massage centers and sessions are available in order for people to have a quiet and stressfree time for themselves. There is also a link below to download a pdf version of our intake form which can be printed out, filled in and brought to your first session. I have listed below any limitations in massage procedures for this patient. Make sure massage clients are healthy before their spa appointment. You can sign up for massage therapy with massage intake form template and you can create a hipaa compliant.
To save time the day of your session, please take a moment to fill out the. Spring into action against allergies massage therapy. Sprains or strains have you had a professional massage before. Massage therapy appointments are currently unavailable. Also known as client intake form, a massage intake form is a way by which therapists record patient contact information, specify policies, and get an idea of the patients issues, medications, and contraindications. With the form, the massage therapy center can collect the basic data and the medical details of the. Patient registration forms are used to register patients for procedures offered at medical facilities. A referral from your primary care provider may be required prior to service being provided. I understand that although massage therapy can be very therapeutic, relaxing and reduce muscular tension, it is not a substitute for medical examination, diagnosis and treatment. The form has four sections namely the client information section, session information section, previous history section, and an acknowledgment section. An informed consent and waiver form should also be enclosed with the therapy intake form to assure that the. These services are not a substitute for medical or veterinary care. I am aware of the benefi ts and risks of massage and give my consent for massage. I affirm that i have notified my therapist of all known medical conditions and injuries.
Client intake questionnaire please fill in the information below and bring it with you to your first session. Nov 28, 2018 21 posts related to client intake form massage therapy template. Pregnancy massage client intake form 1 massage therapy. Bellman, lmt, bs healing arts of ohio, 185 wapakfryburg rd, wapakoneta, oh 45895. I understand that essential oils and aromatherapy is a complementary.
Oncology massage intake form must accompany a complete. Medical history in order to plan a massage session that is safe and effective, i need some general information about your medical history. Copper rain does not perform any massage without proper draping. New patients new patients, prior to your first massage appointment, please print out the patient intake forms, complete the forms at your.
Because massage may be contraindicated for specific medical conditions, i hereby release the massage therapist from any liability if i should intentionally or unintentionally omit information regarding any medical condition that i may have. Massage therapy is not a substitute for medical examination and diagnosis. Because massage should not be performed under certain medical conditions, i affirm that i have stated all my known medical conditions, and answered all questions honestly. Ive also benefitted from the free intake forms and things like that which you put out there. Since the therapy intake form will gather the personal information of the client, it is significant that the therapist has acquired the clients legal consent to use all the statements and details that the client disclosed in the form. Cupping therapies are adaptation of an ancient technique and possess the benefits of traditional use. Payment policy i, the undersigned, understand and agree to the payment policy. I understand that massage therapy is given for the purposes of stress reduction, increased circulation and relief from muscular. Because massage and bodywork therapy may be contraindicated due to certain medical conditions, i affirm that i have informed the therapist of all known medical. Also known as client intake form, a massage intake form is a way by which therapists record patient contact information, specify policies, and get an idea of the. If more information is needed for treatment purposes, your therapist will ask during subsequent sessions. I have completed this form to the best of my ability and knowledge and agree to inform my reflexologist if any of the above information changes at any time.
This is a therapeutic massage and any sexual remarks or advances will terminate the session and i will be liable for payment of the scheduled treatment. The massage therapist will not perform breast massage on female clients without the written consent of the client elements does not perform breast massage. Screen out coronavirus with your massage therapy intake form. Please list current medications, including aspirin, herbs, supplements, etc. The following information will be used to help plan safe and effective massagesessions. Mental health intake form all information on this form is strictly confidential patient first name. I understand that the massage therapist does not diagnose illness, disease or any other physical or mental conditions, nor. Feel free to ask any question about the information being requested. I have completed this health form to the best of my. I understand that bodywork is a health aid and does not take the place of a physicians care. Per texas law, therapeutic massage on an animal is required to be done under the direct or general supervision of a.
Therapeutic massage would, in my opinion, be an acceptable form of adjunctive care during her pregnancy. New patient massage intake forms boulder therapeutics. Massage therapy intake contains different questions about personal information, contact information, history of pathology and the clients symptoms. Use amtas client intake forms to fully understand your client before you begin your first. Client intake form massage therapy greeley colorado. Prenatal massage therapy intake form confidential information todays date name date of birth address. Client intake form therapeutic massage personal information. Keep track of your massage clients condition and progress with sample soap notes. If you have any health concerns regarding your animal, you should consult a licensed veterinarian as soon as possible. As massage is a therapy, the therapist providing the massage requires clients to complete a massage intake form. The form is intended as an assessment tool only and serves as a guide for the applica on of massage not for medical treatment or medical assessment. Client waiver form please take a moment to read the following statements. Use amtas client intake forms to fully understand your client before you begin your first massage session.
Neuromuscular massage therapy client intake form template. I understand that if the massage therapist starts a session late, she will make it. I understand that the massage bodywork i receive is provided for the basic purpose of relaxation and relief of muscular tension. A massage therapy intake form is a powerful means of building trust in the therapeutic relationship. Massage therapy intake form templates creating your form templates is easy with our form editor, but you can also just send us your existing forms and we will set everything up for you. Since the therapy intake form will gather the personal information of the client, it is significant that the therapist has acquired the clients legal consent to. It is recommended that i see a physician for any physical aliment that i may have. I agree to keep the therapist updated as to any changes in my medical profile and. Please use one of the drawings on the following pages to indicate areas of discomfort or unusual sensations that you experience. Keep track of your massage clients conditions and progress by using our free soap notes form. I understand that massage therapy is a therapeutic health aide and is nonsexual. Simply learning to utilize an intake form can be the positive change you are looking for to.
Massage experience have you ever had a massage before today. Zen shiatsu therapy intake form mind body and flow. Since the therapy intake form will gather the personal information of the client, it is significant that the therapist has acquired the clients legal. Therapeutic massage and manual lymphatic drainage intake form. This is the common type of massage intake form that can be provided to all massage clients. Please list current medications, including aspirin, herbs. Ive also benefitted from the free intake forms and things. I have also informed the therapist of all medical conditions and understand that some medical conditions are contraindicated for massage therapy. The form has four sections namely the client information section, session information section, previous history. Massage therapy client intake form template jotform.
Explore the massagehealth connection and see how you can help your clients with a variety of medical challenges. Underline past conditions check here if explanation below. The therapist will massage the necessary body parts to facilitate the massage excluding any contraindicated areas. I understand that massage therapy is given for the purposes of stress reduction, increased circulation and relief from muscular paintension. Massage tips, massage benefits, massage techniques, massage therapy, massage room, foot massage, massage intake forms, massage pictures, chakras reiki wenmink massage business nursing notes nursing tips nursing programs lpn programs certificate programs nursing career spine health medical technology computer science.
It was exactly what i needed and then somei signed up. Client intake form therapeutic massage webster muscular. New patients new patients, prior to your first massage appointment, please print out the patient intake forms, complete the forms at your convenience, then bring them with you to your appointment. Please answer the questions to the best of your knowledge. Protect yourself, your clients and your massage therapy practice by utilizing proper documentation techniques. Name phone day phone eve address citystatezip email date of birth occupation emergency contact phone the following information will be used to help plan safe and effective massage sessions. Proper draping will be used throughout the massage. Also, client intake form massage is used by chiropractors. I have completed this health form to the best of my knowledge. Patient intake form pdf new patient forms massage therapy intake form acupuntura. Client intake form use a client intake form to fully understand your client before you begin your first massage session. Massage therapy has numerous benefits for many health conditions.
If at any time the client is uncomfortable with the massage, the therapist will. Name phone day phone eve address citystatezip email date of birth occupation emergency contact phone the following. Elizabeth bosse, licensed massage therapist and energy. The detailed forms provided below can be downloaded and printed so they may be completed prior to your appointment. The therapist will not work the breast area without written consent by the client. I use a variety of techniques throughout my massages, based on what i find is going on in the tissue. Thank you for scheduling your massage therapy appointment with us, we look forward to working with you. Current symptoms checklist please check all appropriate columns. These include swedish, deep tissue, trigger point, sports, prenatal, massage for relaxation and relief of muscle pain.
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