Green Pastures Still Waters LLC

Green Pastures Still Waters LLC

Patient Data (Confidential)
Name*

First NameLast Name
Please enter at least one phone number.
Cell Phone Number

Area CodePhone Number
Home Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Prefer number to call?

CellHomeWork
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Age
Marital Status

SMWD
Email*
example@example.com
Employer
Occupation
In the event of an emergency, whom should I notify?*

First NameLast Name
Emergency Phone Number*

Area CodePhone Number
Relationship to client
Primary Care Physician

First NameLast Name
Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician Phone Number

Area CodePhone Number
VISIT DETAILS:
Is the client a minor (Under 18 years of age)?

YesNo
IF PATIENT IS A MINOR: Permission is hereby given by me to the massage therapist of this office to treat this patient. I am his/her legal guardian.
Guardian Name

First NameLast Name
Guardian Signature

Clear
Do you frequently suffer from stress?*

YesNo
Do you bruise easily?*

YesNo
Do you suspect that you might be pregnant?*

YesNo
Due Date

MonthDayYear
Date
Are you currently taking any medications for the following:*

Blood ThinnersMuscle RelaxantsBirth ControlAnti-inflammatoryHigh Blood PressurePain RelieversDiabetesNo MedicationsOther
Have you ever had any surgical procedures (past 2 years)?*

YesNo
Please Describe Surgical Procedures (When? / What?)
Have you been in an accident or suffered any injuries in the past two years?*

YesNo
Please Describe Accidents or Injuries (When? / What?)
Do you have any numbness or stabbing pains anywhere?

YesNo
Past Medical History
Please check the appropriate box for any of the following symptoms which you now have or have had previously. Please take your time and answer each question carefully.

THIS IS A CONFIDENTIAL HEALTH REPORT
History*

Abdominal PainArthritisFibromyalgiaInsomniaVaricose VeinsCancerContagious diseaseCarpal Tunnel SyndromeAllergies (food, perfume,etc)High Blood PressureHeart Attack/diseaseSprain/StrainDizziness/FaintingOsteoporosisScoiiosisBursitisHeadachesStrokeSciaticaUlcerDiabetesGoutSeizure/EpilepsyPsoriasisFatigueFractureNoneOther
Back Pain:*

NeckMid backLow BackSacroiliacTailboneNo Back PainOther
Are there any other medical conditions your therapist should be aware of?*

YesNo
Medical conditions your therapist should be aware of:
Are you currently taking any medications?*

YesNo
List Medications (Group of Medications)
Do you wear contacts?*

YesNo
Do you have any of the following today?*

SunburnIrritated Skin RashHeadacheCold/FluSevere PainPoison IvyInflammationOpen cuts, bruises, burnsNoneOther
Have you ever had a massage before?*

YesNo
What kind of massage?

SwedishDeep TissueOther
What are your expectations/goals for this therapy session?*
Covid Intake Form

To best protect your health and the massage therapist, please fill out this form before each massage. Thank you!
Have you been tested for COVID-19?*

YesNo
What type of test did you have? (COVID-19)
When was your test? (COVID-19)

MonthDayYear
Date
What were the results? (COVID-19)
Have you been in places with a high infection rate within the last two weeks (e.g., state-designated "hotspots")?*

YesNo
Please explain. (COVID-19)
Please check if you are experiencing any of the following as a NEW PATTERN since the beginning of the pandemic:*

FeverNasal, sinus congestionChillsLoss of sense of taste or smellCoughFatigueSore ThroatShortness of breathDiarrhea, digestive upsetSudden onset of muscle soreness (not related to a specific activity)Rash or skin lesions (especially on the feet)None
Do you have any new discomfort with exertion or exercise?*

YesNo
I declare that the information provided above is true and accurate to the best of my knowledge.
Please read the following and sign below: I understand that massage is not a replacement for medical care and that no diagnosis will be made, if you have a specific condition or specific symptoms, massage therapy may be contraindicated. A referral from your primary care provider may be required prior to service being provided.
Signature*

Clear
Green Pastures Still Waters
Massage Therapy and Spa
Massage Therapy Informed Consent

I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. I hereby request and consent to the performance of massage therapy on me {or on the patient named below, for whom I am legally responsible) by the therapist (s) of Green Pastures Still Waters Massage Therapy.

If I experience any pain or discomfort during this session, I will immediately inform the massage therapist so that the pressure and/or strokes may be adjusted to my level of comfort.

I have had an opportunity to discuss with the massage therapist the nature and purpose of massage therapy. I understand that results are not guaranteed. I have been informed of other heath care options that may also help my condition.

I understand and am informed that in the practice of massage therapy there are some risks to treatment, including but not limited to: bruising, muscle soreness. I do not expect the therapist to be able to anticipate and explain all risks and complications, and I wish to rely upon the therapist to exercise judgment during the course of the procedure which the therapist feels at the time, based upon the facts then known to him or her, is in my best interest.

I further understand that massage 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 therapists 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.

! have read, or have had read to me, the above consent. 1 have also had an opportunity to ask questions about its content, and by signing below I agree to the above named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.

Because massage therapy 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 my therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist'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.
Informed Consent Signature*

Clear
Green Pastures Still Waters
Massage Therapy and Spa

Office Policy

APPOINTMENT POLICY;

• If you are unable to keep your appointment for any reason, I require that you call immediately to cancel/reschedule.

• When entering the office, please wait in waiting room at the top of the stairs. I will attempt to honor all appointments at the scheduled time. If you are late, you may have to wait for the next available appointment or reschedule for another day.

FINANCIAL POLICY:

• It is the office policy that all services rendered in this office are charged directly to you, the client, and that you are personally responsible for all payments.

• All payments are expected at time of service. Patient's balance may not exceed $100 at any time.

• Acceptable forms of payment include cash and check. All checks for massage therapy should be made payable to 6reen Pastures Still Waters Massage Therapy. Now also accepts credit cards.

• Returned checks are subject to a $25.00 fee.

• Balances over 30 days may be subject to additional collection fees and interest charges of 1.5% per month.

• I reserve the right to charge for missed appointments.

• This office currently does not accept insurance, however, you may submit any receipts for service directly to insurance provider for reimbursement (partial). You must contact your insurance provider for instructions on the reimbursement procedure.
Office Policy Signature*

Clear
Should be Empty: