Therapeutic Bodywork Intake

Energy Matters uses HIPAA compliant applications for both email and texting. However, this protection is one-way and does not cover any data breaches on your end. Although unlikely, emails and texts you receive and send via the Internet may be intercepted by third parties. Hence, the privacy of emailed and texted health care data cannot be assured. Clients who choose to communicate via email and/or text messaging thus consent to an email and/or text exchange with the recognition that HIPAA-related privacy rights cannot be guaranteed.

Please note that email and/or texting are our primary modes of communicating scheduling and billing information to our clients. If you opt-out of receiving reminder emails/texts, we advise that you keep good track of your appointments as we do have late cancel/no show fees.

Billing: If for any reason you are unable to pay at the time of service, an invoice will be mailed to the mailing address you provided. All invoices are on net 15. If we do not receive your payment within 15 days of the due date, please be advised that we may charge you for the full fee for your treatment/service (you may ask for a copy of our most current Fee Schedule).

Emergency Contact

Sign up to receive our Energy Matters newsletters and get a 15% off discount on your next herb/supplement and/or retail purchase*. You’ll get 4 to 8 emails per month that focus on helping you live a healthier life with informative articles, special deals, and more. You can also choose to decline the offer below.

*You'll get a one-time, 15% discount off of a total purchase of herbs, supplements, and/or retail including food, face & body products, Qigong books and dvds. Not applicable for Multi-pure products. Applies for in-person or via phone or email orders only. Discount cannot be applied to orders purchased through the Energy Matters Online Store (Marketplace). Energy Matters newsletters are sent through Mailchimp - a non-HIPAA compliant email and marketing platform. By agreeing to sign up for Energy Matters newsletters, you agree to share the following Personal Health Information: Full Name and Personal Email Address.

Payments Policy
Patients are responsible for paying fees at the time of service. We accept cash, check, all major credit cards, debit cards and HSA/FSA cards. There is a $20.00 service charge for returned checks.

Invoice payments are due upon receipt. 

Late Payment Warning
If you have received the Prompt Pay Discount for your services (see Fee Schedule*, p 1, col 2), and we do not receive your payment within 15 days of the due date, please be advised that we may charge you for the full fee for your treatment/service (see p 1, col 3).

Herbal products, supplements and skin care products may not be returned.

See *Fee Schedule Handout here: https://bit.ly/3euoIUn

By initialing below, you acknowledge receiving and understanding the Payments Policy.

Cancellation Policy

At Energy Matters, our mission is to return your body to the way it was meant to function every day, in full harmony and vitality. As a patient at Energy Matters, you are asked to agree to the following policies so that we can ensure the best possible health care experience for you while sustaining the livelihood of Energy Matters staff. We understand that life is complicated and unexpected things happen. Nonetheless, we require advanced notice for appointment cancellations and charge a fee for late cancellations and no shows. See Late Fees on p2 here: https://bit.ly/emcancel

By initialing/signing below, you acknowledge receiving and understanding the Cancellation Policy.

Informed Consent to Treat

Informed Consent to Treat

I understand that massage and bodywork (Craniosacral Therapy, lymphatic drainage, or other technique) provided by Ana Fletes of Energy Matters Acupuncture & Qigong is intended to enhance relaxation, reduce pain caused by muscle and other soft tissue tension or restrictions, increase range of motion, improve circulation, and offer a positive experience of touch.

The general benefits of massage bodywork, possible contraindications, and the treatment procedure have been explained to me. I understand that massage therapy and bodywork is not a substitute for medical treatment or medications and that it is recommended that I concurrently work with my primary caregiver for any condition I may have. I am aware that chiropractic spinal adjustments are not part of massage therapy.

• I have informed my massage therapist/bodywork practitioner of all my known physical conditions, medical conditions, and medications (including herbal remedies and supplements), and I will keep the practitioner updated on any changes that occur.
• I agree to obtain a medical release if required by my therapist for any specific health conditions.
• I realize that I have the right to refuse, modify, or terminate massage therapy or bodywork treatment at any time.
• I understand and agree that my practitioner has the right to terminate any session and refuse further treatment for inappropriate requests or suggestions of a sexual nature.

COVID-19
I understand that the novel Coronavirus (COVID-19) has been declared a global pandemic by the World Health 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. Part of this office’s role is to 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.

To proceed with receiving care, I confirm and understand the following:

• I understand my treatment may create circumstances, such as the discharge of respiratory droplets or person-to-person contact, in which COVID-19 can be transmitted.
• I understand that I am opting for an elective treatment that may not be urgent or medically necessary, and that I have the option to defer my treatment to a later date. However, while I understand the potential risks associated with receiving treatment during the COVID-19 pandemic, I agree to proceed with my desired treatment at this time.
• I understand due to the frequency of appointments with patients, the attributes of the virus, and the characteristics of procedures, I may have an elevated risk of contracting COVID-19 simply by being in a healthcare office.
• I am informed that you and your staff have implemented preventative measures intended to reduce the spread of COVID-19. However, given the nature of the virus, I understand there may be an inherent risk of becoming infected with COVID-19 by proceeding with this treatment. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective treatment and give my express permission to you and the staff at your offices to proceed with providing care.
• I can download a copy of the Informed Consent to Treat here: https://bit.ly/emconsenttreat

I HAVE READ, OR HAVE HAD READ TO ME, THE ABOVE INFORMED CONSENT TO TREAT. I APPRECIATE THAT IT IS NOT POSSIBLE TO CONSIDER EVERY POSSIBLE COMPLICATION TO CARE. I UNDERSTAND THAT I WILL HAVE 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.

By initialing and signing below, you acknowledge receiving and understanding the Informed Consent to Treat.

Notice of Privacy Practices

Energy Matters Acupuncture & Qigong, including staff, is required by law to maintain the privacy and confidentiality of your protected health information, and to provide patients with notice of our legal duties and privacy practices with respect to your protected health information. Protecting the privacy of your personal health information is important to us. This notice describes how information about you may be used and disclosed, and how you can access this information. Please read carefully.

Disclosure of your protected health information without authorization is strictly limited to defined situations including emergency care, standard health care operations, public health, research, and law enforcement activities. Any other disclosure for the purposes of treatment, payment, practice or operations will be made only after obtaining your consent. You may request restrictions on disclosures. Disclosures of protected health information are limited to the minimum necessary for the purpose of the disclosure. This provision does not apply to the transfer of medical records for treatment. You may inspect and receive copies of your records within 30 days of a request to do so. There may be a reasonable cost-based fee for photocopying, postage and preparation. You may request changes of your records. Our practice has the right to accept or deny your request. We maintain a history of protected health information disclosures that is accessible to you.

Energy Matters uses HIPAA compliant applications for both email and texting. However, this protection is one-way and does not cover any data breaches on your end. Although unlikely, emails and texts you receive and send via the Internet may be intercepted by third parties. Hence, the privacy of emailed and texted health care data cannot be assured. Clients who choose to communicate via email and/or text messaging thus consent to an email and/or text exchange with the recognition that HIPAA-related privacy rights cannot be guaranteed.

Our practice is required to abide by this notice. We have the right to change the notice in the future. Any revisions will be prominently displayed in our office. You may file a complaint about privacy violations by contacting us.

I have read the Privacy Notice and understand my rights contained in the notice. By way of my initials and signature, I provide Energy Matters Acupuncture & Qigong with my authorization and consent to use and disclose my protected health care information for the purposes of treatment, payment, and health care operations as described above.

Low Scent Environment

At Energy Matters, we are a ‘low-scent’ environment. We don’t use any cleaning products or personal care products with ‘fragrance’ in them, and ask our staff and patients to do the same.

When you come to our clinic, please help us create an environment for healing by avoiding scented and fragranced colognes, laundry detergent, dryer sheets, perfumes and body care products.

We do use products with essential oils, as they give scent without the side effects, and offer therapeutic benefits of their own. However, some people are sensitive to essential oils as well. If this is an issue for you, let us know so we can discuss options.