General Client Intake Form 2017

Connective Integration Massage Therapy

Post Operation Augmentation/Liposuction Client Intake Form 2023

All information is held in the strictest confidence. At no given point is information disclosed or shared without client’s written consent. The State of Texas requires all client's to fill out personal and medical information.
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone*

Area CodePhone Number
Cell Phone*

Area CodePhone Number
E-Mail*
Occupation*
Emergency Contact*
Emergency Contact Phone Number*

Area CodePhone Number
How did you hear of my services?*
What is the name of the person that referred you?*
Medical Information & Questionaire
Select all that apply:*

High Blood PressureLow Blood PressureBlood Clots/PhlebitisThyroidGraves DiseaseLyme DiseaseLupusHypoglycemiaHyperglycemiaHashimoto's DiseaseRaynaud's DiseaseMultiple SclerosisChronic FatigueFibromyaligiaStiffnessSpider/Varicose VeinsLow Back PainSciaticaBursitisSkin InfectionContagious ConditionsCancerSwellingVision IssuesAllergiesOsteoporosisAIDS/HIVBruisingDiabetesHeart AttackTMJ SyndromeTuberculosisDizzinessSprainStrain ArthritisHeadaches/MigrainesAthlete’s FootStrokeCirculatory ConditionsCardiovascular DiseasePre/Post SurgeryLymphedemaLipedemaParalysisSeizuresInfertilityAuto Immune DiseaseBreast IssuesVertigoGriefPTSDStressRotator Cuff InjuryEdemaDepressionCarpal TunnelTendinitisPlantar FasciitisAllergiesTraumatic Brain Injury (TBI)None of the aboveDental Issues/Root CanalPost Covid-19 SymptomsOther
Please explain if you checked off allergies, cancer, Post covid-19 symptoms, contagious condition, or other.
Please list and indicate dates of previous surgeries, auto accidents, traumas, or chronic illness within the past ten years if not longer.*
Have you been diagnosed with COVID-19? If yes please contact your therapist before proceeding. This includes exposure of any kind.*

YesNo
Do you have any of the following?

Pace MakerColostomy bagNerve StimulatorDiabetes Monitor
Are you menstruating?*

YesNo
Date of your last menstrual cycle.*
Are you currently on birth control? *

YesNo
Are you have complications after your surgery due to your birth control medicine such as blood clots?*

YesNoOther
Select all that apply:*

EndometriosisFibroid TumorsUterine CancerPainSwellingPremenstrual SyndromePremenstrualExcessive bleedingSevere Blood Clotting During MenstruationFull HysterectomyPartial HysterectomyPoly-cystic Ovarian Syndrome (PCOS)Coccyx DysfunctionTilted UterusUTICesareanOther
Do you have a history of urinary tract infection (UTI)?*

YesNoUnsure
Are you currently under the care of a physician (doctor/surgeon)?*

YesNo
Name and phone number of your physician and/or surgeon. A phone number is required*
Doctor's clearance is required if you are under six weeks post operation. Please attach any medical releases/documentation here:

Upload a File

Cancelof
Are you taking any medication? *

YesNo
List the medications and supplements you are taking.*
Would you like aromatherapy for your session? *

YesNo
Are you allergic to scents, any oils or lotions?*

YesNo
List allergies/interactions.*
Any part of the body that you do not want massaged? (example: feet, scalp, hands, stomach)
Please rate your tension level from 1-10 (1 lowest - 10 highest)
Please rate your pain level from 1-10 (1 lowest -10 highest
Describe your pain. Check all that applies.*

DullThrobbingPin & NeedlesNumbnessSharpAchingBurningConstantIntermittentOccasionalOther
What part of the body you feel the pain is coming from?
How long have you been in discomfort?
What improves or worsens the condition?
The Procedure
What was the date of your Augmentation/liposuction surgery?*
What was the name of the doctor and/or the practice that performed your surgery? Give the city,state or country in which it was performed.*
Are you recovering from breast augmentation surgery?*

YesNo
Are you recovering from liposuction surgery?*

YesNo
Did you have surgery for Abdominoplasty (tummy tuck; repair of abdominal muscles) performed?*

YesNoOption 3
Did you have surgery for a Panniculectomy Abdominoplasty (no repair of abdominal muscles)?*

YesNo
If so did you have traditional liposuction performed?*

YesNo
Did you have laser lipo performed?*

YesNo
Did you have a Brazilian Butt Lift (BBL/fat graph) procedure?*

YesNo
Did you have a explant surgery?

YesNo
Do you have expanders?

YesNo
Did you have a fat transfer breast augmentation?*

YesNo
Do you have any scar tissue from previous surgeries?*

YesNo
Do you have any open wounds or surgical incisions that are not healing?*

YesNo
Do you currently have a fever?*

YesNo
Do you have any discharge from the wound/surgical opening?*

YesNo
Do you have a rash that is hot to the touch?*

YesNo
Have you been diagnosed with cellulitis? A doctor's clearance and a release are required before you are seen.*

YesNo
Have you been diagnosed with fibrosis?*

YesNo
Are you having difficulty healing after your surgery?*

YesNo
Have you been diagnosed with a seroma (pocket of fluid under the surface of the skin)?*

YesNo
Were you diagnosed with a hematoma (a solid swelling of clotted blood within the tissues.)? A doctor's clearance and a release are required before you are seen. *

YesNo
Were you diagnosed with phlebitis (blood clots). A doctor's clearance and a release are required before you are seen. *

YesNo
Please explain if you said yes to any of the questions above.
Have you been currently or even previously diagnosed with a hernia?*

YesNo
Breast Lympahtic Drainage & Massage Waiver
Would you like breast lymphatic drainage with breast massage with your session? Recommended and beneficial after augmentation surgery.*

YesNoUnsure
It is my choice to receive breast lymphatic drainage and/or breast massage. I have given the therapist written and verbal permission to administer breast lymphatic drainage and/or breast massage. I understand that the treatment being given is for the purpose of improving breast health and recovery after surgery. These techniques are designed to reduce tenderness, pain and swelling, enhance circulation and lymphatic flow, and to provide stress reduction and relief from muscular discomfort after surgery. You must sign and date below for breast lymphatic drainage and/or breast massage. For all future sessions you must request and give verbal permission to receive this service.
Signature*

Clear
Client Waiver & Release Form

Massage therapy helps to increase circulation, range of motion and flexibility while decreasing restrictions of the muscular system and soft tissues. While massage may aide in reduction of nerve pain it does not repair nerve damage. Massage will not repair damaged or degenerative vertebrae(s), or torn ligaments and tendons.

You understand that the therapist does not re-open surgical incisions nor "push" fluids/lymph through surgical incisions nor drains. Your drains must be removed and all surgical incisions that have not healed must be covered with a bandage before you are seen. Therapist does not work under the scope of a doctor. Therapist cannot repair surgical neglect caused by liposuction/augmentation/explant procedures.

If you under six weeks post operation you are required to obtain a release/note from your surgeon or primary care doctor. Chiropractor's notes are not accepted.

The session consists of therapeutic, clinical massage that entail a variety of techniques such as Swedish, fertility, deep tissue, medical, hot stone, cold stone, bamboo, Fijian and sports massage but not limited to medical cupping, radio frequency therapy, castor oil packs, kinesio taping, stretching, reflexology,energy therapy, Reiki, myofascial release, manual lymphatic drainage, craniosacral, and trigger point therapy. There might be a small degree of bruising, swelling, and/or tenderness involved for modalities such as trigger point therapy, deep tissue massage, vacuum/medi cupping, Gua Sha or any technique that requires going into the superficial layers of muscles and tissues. The areas that will be massaged will be scalp, face, neck, back, shoulders, chest, arms, abdomen, buttocks, thighs, legs, and feet.

Manual Lymphatic drainage requires access to the sternum, above the pelvic bone, lower lumbar region, back of the knees and bends of the arm. This includes working and opening lymphatic channels located in the torso, upper pelvic area and inner thighs.

Craniosacral Therapy requires working in sensitive areas such as the thoracic, sacrum, and pelvic diaphragms. A sheet will be between the therapists hands and the client's body.

This office does not provide Clear Path Massage (uterus massage), prostrate massage, detox massage, physical therapy nor chiropractic adjustments.

Contradictions for massage are as followed: Any contagious virus or disease such as flu (influenza), SARS, H1N1, COVID-19, vaccinations/boosters, upper respitory infection, the common cold, pneumonia, acute bronchitis, impetigo (ringworm), lice, scabies, mumps, chicken pox, shingles, fever, athletes foot, mono, cellulitis, tuberculosis (consumption), phlebitis (blood clots) and MRSA, streph throat, meningitis and hepatitis. Skin problems such as severe acne and aliments such as high blood pressure, hematoma, deep vein thrombosis, certain cancers, some autoimmune diseases, severe migraines and edema are contradictions as well. Please consult your therapist if you have any of these conditions or any other possible contagious and infectious diseases not listed.

If you have a cold, flu or any contagious virus or disease you are required to reschedule your massage session at a later date. Sessions will be canceled and you will be refused service if you show symptoms of illness and/or running a fever.

Castor oil packs, candling and radio frequency are not covered under the therapist liability insurance. If you decide and agree to participate in these procedures you do so at your own risk. The therapist will not be held liable for your participation of these procedures.

There is a possibility that Jarisch-Herxheimer Reaction (healing crisis) may occur after your massage session. Herxheimer is a reaction when the body removes metabolic waste (endotoxins from pathogen die off) too quickly. You may experience breakouts, rashes, headaches, nausea, fatigue, soreness, or flu like symptoms.

Unknown allergies to products may occur. Inform your therapist if you are sensitive to scents, oils or lotions before your massage session.

Vaccinations/Boosters:

Due to possible side effects of any vaccination you are required to wait 7 to 14 days before scheduling your appointment. You may schedule your session before your shot or wait 7 to 14 days after your shot.

Communication:
If you have any questions, comments, or concerns please feel free at ask them before, during, or after the session. If you experience discomfort or pain during the session, please inform the therapist. Therapist will not be held liable if you do not communicate. If you feel uncomfortable during the session and would like it to cease, please inform therapist and the session will stop immediately.

For privacy compliance, you will be seen alone for some duration of your session time. Friends and family members are not permitted to sit in with you during your session. Exceptions will be made for adolescent clients, guardian, care provider and/or interpreter.

Due to HIPPA your records will not be released to anyone without your verbal or written permission unless subpoenaed by the courts.

Due to privacy and HIPPA regulations no voice, camera or video recordings are permitted during your session unless verbal and written permission is given from both client and therapist.

Fees/Failure to Show:
Office visit rates will vary. 1 hour rate is $90. 90-minute is $130. 2 hour rate is $170. Prices are subject to change without notice. After hours fee of $25 will be assessed for massage scheduled after 7 p.m. A $35 fee charged on all return checks or credit card charge backs. No refunds for services rendered, prepaid sessions or on gift certificate purchases. 50% of the orginal fee will be charged for same day cancellation. 100% of service fee will be charged or gift certificate forfeited for failure to show to your appointment. Failure to pay will result in collection and additional legal fees. Any form of Insurance is not accepted for payment. Payment is due when services are rendered. Receipts/invoices are provided by electronic email or text message with a CPT Code, modaility and rate for insurance purposes. Therapist cannot guarantee reimbursement from auto and health insurance plans or medical flex spending accounts. Susan Walker LMT is not a approved Medicare or Medicad provider. I do not accept Letter of Protection or Promise to Pay for payment.

Late Arrivals:
Please arrive early to your appointment. If you are more than five minutes late, time may be docked from your session due to time restraints. If you are 15-minutes or more late, you may take the remainder of the session time. You will be charged for the full amount of the session price. No rescheduling for late arrivals.

Draping Policy:
Draping is required. Draping (a towel or sheet cover) will be provided.

I hereby acknowledge that all information provided is complete and accurate to the best of my knowledge and that I will notify the therapist of any changes in my physical condition prior to my massage session. I have read and agree with the above waver and release above. I hereby release and understand there shall be no liability whatsoever placed on the therapist Susan D. Walker, MT 104431 because of my volunteer election to participate as a client. I Understand that the therapist will not be held liable for any underlying medical condition not diagnosed by a doctor that may cause complications after my massage session. I understand that I will not hold the therapist liable to any possible exposure or unknown exposure to any contagious virus or disease. I understand that it is out of the scope of practice for a massage therapist to perform manual manipulation, physical therapy, chiropractic treatment care, diagnose medical conditions or provide mental healthcare services. Massage therapy is not substitution for medical treatment. Massage Therapist cannot diagnose, treat or prevent disease. Please consult your physician for medical care.
Electronic Signature:*

Clear
Date*

MonthDayYear
Print Full Name: ____________________________________ Date of session: ________________________
Therapist Signature_________________________________ Date of session: ________________________________
Should be Empty:

Client Waiver & Release Form