• Client Health Intake Form

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  • Todays date*
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  • Your scheduled appointment date
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  • ________________________________________

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  • How long is your treatment?*

  • _______________________________________

    This document contains important information about your decision to receive services in light of the COVID-19 public health crisis. Please read and fill out this form carefully and let me know if you have any questions. If you have a specific medical condition or specific symptoms, massage/bodywork may be contraindicated. A referral from your primary care provider may be required prior to service being provided. To proceed with receiving care, I confirm and understand that by electronically signing and submitting this form, I am agreeing the following. I understand that the novel Coronavirus (COVID-19) has been declared a global pandemic by the WorldHealth Organization (WHO). I further understand that COVID-19 is extremely contagious and may be contracted from various sources. I understand COVID-19 has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. I understand that I am the decision maker for my health care. To the best of their ability, my practitioner will provide me with information to assist me in making informed choices. This process is often referred to as “informed consent” and involves my understanding and agreement regarding recommended care, and the benefits and risks associated with the provision of health care during a pandemic. Given the current limitations of COVID-19 virus testing, I understand determining who is infected with COVID-19 is exceptionally difficult. I understand that preventative measures and intensified sanitation protocols intended to reduce the spread of COVID-19 have been implemented. However, because this work involves close physical proximity over an extended period of time in a closed space, there may be an elevated risk of disease transmission, including COVID-19. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this treatment and give my express permission to you and the staff at your office to proceed with providing care. I KNOWINGLY AND WILLINGLY CONSENT TO THE TREATMENT WITH THE FULL UNDERSTANDING AND DISCLOSURE OF THE RISKS ASSOCIATED WITH RECEIVING CARE DURING THE COVID-19 PANDEMIC. I CONFIRM ALL OF MY QUESTIONS WERE ANSWERED TO MY SATISFACTION.I HAVE READ, OR HAVE HAD READ TO ME, THE ABOVE COVID-19 RISK INFORMED CONSENT TO TREAT. I APPRECIATE THAT IT IS NOT POSSIBLE TO CONSIDER EVERY POSSIBLE COMPLICATION TO CARE. I HAVE ALSO HAD AN OPPORTUNITY TO ASK QUESTIONS ABOUT ITS CONTENT, AND BY SIGNING BELOW, I AGREE WITH THE CURRENT OR FUTURE RECOMMENDATION TO RECEIVE CARE AS IS DEEMED APPROPRIATE FOR MY CIRCUMSTANCE. I INTEND THIS CONSENT TO COVER THE ENTIRE COURSE OF CARE FROM ALL PROVIDERS IN THIS OFFICE FOR MY PRESENT CONDITION AND FOR ANY FUTURE CONDITION(S) FOR WHICH I SEEK CARE FROM THIS OFFICE.
  • Have you had a fever in the last 24 hours of 100°F or above?
  • Do you now, or have you recently had, any respiratory or flu symptoms (including fever, chills, sorethroat, cough, muscle aches, or shortness of breath)?
  • Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 orhas coronavirus-type symptoms?
  • Have you traveled anywhere outside of the state in the last two weeks?
  • Have you had a new loss of sense of taste or smell?
  • Have you had a new loss of sense of taste or smell?
  • Diabetes?*
  • High/Low Blood Pressure*
  • Alcohol Drug Addiction*
  • Hepatitis*
  • Do you smoke?*
  • Clotting Disorder*
  • Epilepsy or seizures?*
  • Alzheimers*
  • Autoimmune*
  • Chronic Pain*
  • Cancer*
  • Stroke*
  • Have you ever had surgery?*
  • Heart Disease?*
  • Varicose veins?*
  • Contagious deseases?*
  • Do you wear dentures?*
  • Are you pregnant?*
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  • Allergies?*
  • Any injuries in the past two years?*
  • Physical, emotional, metal stress?*
  • Numbness or stabbing pains?*
  • Check each that you currently use:
  • General
  • Nose and Sinuses
  • Males Only
  • Immune
  • Genito-Uninary
  • Head and Neck
  • Skin
  • Mouth and Throat
  • Mental / Emotional
  • Respiratory
  • Neurologic
  • Cardiovascular
  • Eyes and Ears
  • Circulation
  • Digestion
  • Endocrine
  • Female Only
  • Muscle / Joint / Bones
  • I have difficulty:
  • Emotional Health. Check all that apply

  • ___________________________________

    Cancellation: Amid the ongoing uncertainty of COVID-19, we have modified our cancellation policy to offer greater flexibility to all our clients. We hope this will alleviate any stress and hesitation you have about an upcoming appointment. If you need to reschedule for whatever reason, and especially if you are not feeling well, we understand and request for you to please contact us as soon as possible to reschedule. To further support you, there will be no penalties for cancellations at this time. Tardiness: Appointment times are as scheduled and cannot extend beyond the stated time to accommodate late arrivals. Please be on time to your appointment. Sickness Massage/bodywork is not appropriate care for infectious or contagious illness. Please cancel your appointment as soon as you are aware of an infectious or contagious condition. If it is within the 24-hour notice period, the cancellation fee may be waived. If this office is providing billing services, please be advised of our billing policies. Cancellation: We do not bill insurance companies for missed appointments or late cancellations. You are responsible for paying the missed appointment/late cancellation fees. Financial Responsibility: Once your insurance is verified, we will bill and accept payment from your insurance company for covered services. In the event that the insurance company denies payment or makes partial payment, you are responsible for the balance, deductibles, and co-pays. Your signature below confirms your financial responsibility for all services regardless of insurance reimbursement. Assignment of Benefits:Your signature below authorizes and directs payment of medical benefits to the massage/bodywork practitioner for services provided by this office. Release of Medical Records: Your signature below authorizes the release of all of your medical records on file in this office, for the purpose of processing your claims, to the following: your attorney, the healthcare providers attending to this condition, and the insurance case managers. Medical records will not be edited unless otherwise stated in an exclusive release of medical records signed through your attorney. I understand that the massage/bodywork I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or application of massage strokes may be adjusted to my level of comfort. I further understand that massage/bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that i should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which i am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage/ bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.

  • HIPPA

    NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION Law requires the privacy of your health information be maintained and that you are provided this notice of the legal duties and privacy practices with respect to your health information. Other than the uses and disclosures we described below, your health information will not be sold or provided to any outside marketing organization. We must abide by the terms of this notice and we reserve the right to change the terms of this privacy notice. If a change is made, it will apply for all of your health information in our files, and you will be notified in writing. HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. USES AND DISCLOSURES Here are examples of use and disclosure of your health care information: 1. We may have to disclose your health information to another health care provider, or a hospital, etc., if it is necessary to refer you to them for the diagnosis, assessment, or treatment of your health condition. 2. We may have to disclose your session records and your billing records to another party (i.e. your insurance company), if they are potentially responsible for the payment of your services. 3. We may need to use any information in your file for quality control purposes or any other administrative purposes to run this practice. 4. We may need to use your name, address, phone number, and your records to contact you to provide appointment reminder calls, recall postcards, Welcome and Thank You cards, information about alternative therapies, or other related information that may be of interest to you. If you are not at home to receive an appointment reminder, a message will be left on your answering machine. YOUR RIGHT TO LIMIT USES OR DISCLOSURES You have the right to request that we do not disclose your information to specific individuals, companies, or organizations. Any restrictions should be requested in writing. We are not required to honor these requests. If we agree with your restrictions, the restriction is binding on us. PERMITTED USES AND DISCLOSURES WITHOUT YOUR CONSENT OR AUTHORIZATION Under federal law, we are also permitted or required to use or disclose your information without your consent or authorization in the following circumstances: 1. We are providing services to you based on the orders (referral) of a health care provider. 2. We provide services to you in an emergency and are unable to obtain your consent after attempting to do so. 3. If there are substantial barriers to communicating with you, but in our professional judgment we believe that you intend for us to provide care. REVOKING YOUR AUTHORIZATION You may revoke your authorization to us at any time in writing. There are two circumstances under which we will not be able to honor your revocation request: 1. If your information has been released prior to your request to revoke your authorization. 165.508(b)(5)(I) 2. If you were required to give your authorization as a condition of obtaining insurance, the insurance company may have a right to your information if they decide to contest any of your claims. CONFIDENTIAL COMMUNICATION We will attempt to accommodate any reasonable written request regarding your contact information that has been provided by you. AMENDING YOUR HEALTH INFORMATION You have the right to request that we amend your health information for seven years from the date that the record was created or as long as the information remains in our files. We require a written request to amend your records that includes a valid reason to support the change. We have the right to refuse your request. INSPECTING/COPYING YOUR HEALTH INFORMATION You have the right to inspect the your files while in our office and/or have a copy made for you. The information is available up to seven years from the date that the record was created. Your request to inspect or obtain a copy of the file must be in writing. There will be a charge of $.20 per page copied. ACCOUNTING OF DISCLOSURES OF YOUR RECORDS You have the right to request an accounting of any disclosures (not listed below) made of your information for six years prior to the date of your request. The request must be in writing. The accounting will exclude the following disclosures: Required for your session, to obtain payment for services, to run our practice, and/or made to you. Necessary to maintain a directory of the individuals in our facility or to individuals involved in your care. For national security, intelligence purposes, or law enforcement officers. That were made prior to the effective date of the HIPAA privacy law (April 14, 2003). We will provide the first accounting within a 12-month period without any charge, but any additional requests will be charged a fee. When you make your request we will tell you the amount of the fee and you will have the opportunity to withdraw or modify your request RE-DISCLOSURE We cannot control the actions of others to whom we have released your information for further treatment. Information that we use or disclose may be subject to re-disclosure by these individuals/facilities and may no longer be protected by the federal privacy rules. COMPLAINTS You may complain to us or to the Secretary for Health and Human Services if you feel that we have violated your privacy rights. We respect your right to file a complaint and will not take any action against you if you file a complaint. Written comments should be addressed to our office address or Secretary for Health and Human Services, 200 Independence Ave. SW, Room 509F, HHH Bldg. Washington, DC 20201. This notice effective as of April 14, 2003. This notice will expire six years after the date upon which the record was created. By signing below, I acknowledge that I was given the opportunity to read and ask questions. I give Touch-For-Life Massage & Wellness my permission for you to leave any information for me and use your name/clinic name at the following:
  • By checking the agree box, I authorize that I have answered all questions honestly, agree to the HIPPA notice and office policies. I am in agreement of myself and/or minor child to have massage/bodywork treatments.
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