New Patient Information

  • New Patient Information

  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • TMJ Questionnaire

  • Symptoms

    Please check all that apply.
  • Jaw Symptoms (check all that apply)*
  • Head/Face Symptoms (check all that apply)*
  • Neck/Body Symptoms (check all that apply)*

  • Symptom Details

  • How would you describe the pain? (check all that apply)*
  • What makes the pain worse? (check all that apply)*
  • What helps with the pain? (check all that apply)*

  • How much do your symptoms affect the following activities?

  • Medical History

    Please check all that apply.
  • Conditions*
  • Surgeries/Injuries*
  • Dental/TMJ History*
  • Medications*
  • Do you have any allergies?*
  • Daily Habits (check all that apply)*

  • Massage Therapy Informed Consent Form

    Please read all of the information and sign below.

  • This record of consent is required before the first assessment or treatment and will be maintained confidentially in the patient file.  It may only be released to a third party with prior or written consent of the patient.

     

    This massage therapy treatment includes the assessment and treatment of the soft tissues and joints of the body using soft tissue manipulation, joint mobilization, remedial exercises and self-care programs as determined by the therapist.  Treatment plans will be discussed with the client prior to the start of treatment.

     

    By signing below, the client agrees with the following:

    • Written consent must be given by me prior to any disclosure or sharing of my personal and clinical information with any third party.
    • All massage treatments, information and records will be kept confidential and securely stored for use only by the massage therapist.
    • The information I have provided on the attached patient information forms is true and correct.
    • Privacy will be assured as I have the right to undress only to my comfort level and according to the requirements of the treatment.
    • Draping will be used by the therapist as required to expose only those parts of my body that require treatment and/or as I choose to ensure my comfort during treatment.
    • If at any time during the treatment I feel uncomforatable with the treatment for any reason, I have the right to request an immediate stop to the session or request modification to the treatment, regardless of prior consent given.
    • The therapist may stop treatment at any time if the patient is in any way inappropriate or acts in a way to make the therapist feel uncomfortable.
    • Promptness is expected for all appointments.  In the event of lateness, the massage may be cut short due to other commitments of the therapist.  Fees will be maintained per the schedule.
    • Cancellation of any appointment must be received at least 24 hours in advance, otherwise 50% of the appointment fee is due.
    • Fees for treatment are due prior to departure on the day of treatment.  Cash, credit card and venmo are all accepted.
    • Ther therapist may refuse to treat any client or part of their body with just and reasonable cause.
  • I have read the above information and consent to the massage treatment for the condition discussed with my therapist today.*

  • Referral

    Before your treatment, a referral from a healthcare professional must be on file.

  • There are 3 ways to send a referral:

    1. Email a referral to Referrals@EricaFenechTMJ.com
    2. Upload your referral below.
    3. Request for your provider to visit the "For Providers" page at www.EricaFenechTMJ.com where they can fill out a referral form.

     

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  • I understand that a referral for my treatment is required before my appointment. My referral has been sent by:*
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