Manual Therapy NYC 

1133 Broadway

@ corner 26th Street, in NoMad

Suite # 1507

New York, NY 10010

1.646.417.1837  |  https://manualtherapynyc.com  |   info@manualtherapynyc.com

Is there a particular area of the body where you are experiencing tension, stiffness or pain? If yes, please identify: indicate the areas in which you are feeling discomfort:

Payment and cancelation Policies

 

100% Full Payment is required for the following conditions: 

• Full payment is required at time of service.
• No Show: If you do not show up for an appointment, you will be charged the full cost for the appointment. Payment is due before your next appointment.

• Late Arrival: If you are late to your session you are welcome to receive whatever time is left in your appointment. Due to our tightly booked schedule we are generally unable to extend your session beyond your original appointment time. Regardless of the length of the service actually given, you will be responsible for payment of the full service you scheduled. Please plan to arrive 10 minutes early for your appointment.

• Last-Minute Cancellation/Reschedule: Failure to cancel or reschedule your appointment at least 24 hours in advance will result in a charge of 100% of the scheduled appointment fee. Payment is due before your next appointment.

• This is a therapeutic session. Sexual advances, request for sexual favors, and other verbal or physical conduct of a sexual nature will constitute a sexual harassment and will terminate the session. I will be liable for payment of the scheduled treatment.

I agree to the Payment and Cancellation Policies above.

Sickness Policy

 

Please reschedule your appointment as soon as you are aware of an infectious or contagious condition. 

 

If you arrive for your appointment with symptoms of an illness, you will kindly be asked to reschedule your appointment to avoid the spread of germs. This protects are most susceptible loved ones - children, the elderly, & people with suppressed immune systems, like cancer patients and patients with auto-immune illnesses. 

 

If you have experienced any covid-19 related sympthoms or travel in one one of the restricted states or territories within the last 14 days, call Delia Ahouandjinou before coming to the office.

 

If any of the following describes you, we kindly ask that you reschedule your appointment  or speak direclty with Delia Ahouandjinou so we can prevent the spread of bugs: 

• Fever or Chills
• Vomiting or Diarrhea 
• Runny Nose 
• Sore Throat or Cough
• Difficulty breathing
• You are currently taking an antibiotic
• You or someone in your direct care has a cold, sinus infection, or flu bug
• You or someone in your direct care has been diagnosed with influenza (the flu)

 

Even if you are cancelling your appointment within the 24-hour notice period, the cancellation fee may be waived; the onset of symptoms doesn't always have great timing, right?

I agree to the Sickness Policy above. I understand that if I show signs of infection when I arrive for my appointment, I may be denied access to the office and asked to reschedule my appointment.

Informed Consent

By typing my first name, last name, and providing my e-signature below, I am indicating the following: 

I understand that Delia Ahouandjinou LMT, CST, does not diagnose illness or disease or other medical, physical or emotional disorder, nor prescribe any medications/treatments. I acknowledge that I am responsible for consulting a qualified physician for any ailments that I may have. If necessary, I allow Delia to discuss with my health care provider the appropriateness of bodywork for my condition.

I have read the New Client Intake Form for Delia Ahouandjinou, LMT CST in its entirety. 

I fully understand all questions and information provided in the New Client Intake Form for Delia Ahouandjinou, LMT CST. 

I have completed the New Client Intake Form for Delia Ahouandjinou, LMT CST accurately and to the best of my knowledge. 

I have read, I understand and I agree to the terms and conditions to receive a session from Delia Ahouandjinou, LMT CST.  

 

I shall take it upon myself to inform Delia Ahouandjinou LMT, CST of any changes.

 

If I experience any pain or discomfort during this session, I agree to immediately inform Delia so that the pressure and/or methods can be adjusted to my comfort level. The therapist reserves the right to refuse services for any reason of safety.