Client Intake

Client Health History Intake Form
To be filled out and returned to me on your first visit.
scan0002.pdf
Adobe Acrobat document [511.7 KB]
Side 2 Cient Health History Intake Form
To be filled out and returned to me on your first visit. *Please don't forget to sign and date.
scan0003.pdf
Adobe Acrobat document [586.5 KB]
Initial Injury Evaluation
To be filled out and returned to me if you have been injured on the job and are be treated with an open L&I claim *or if you have been in an motor vehicle accident and are being treated with an open P
scan0007.pdf
Adobe Acrobat document [439.5 KB]
Informed Consent/Cancelled-Missed Appointment Form
To be filled out and returned to me on your first visit.
scan0020.pdf
Adobe Acrobat document [784.5 KB]
Physician Prescription
To be filled out and returned to me - Required for all Insurance Treatment, Workman's Comp., or Personal Injury Protecton.
scan0001.pdf
Adobe Acrobat document [477.8 KB]
Activities Of Daily Living Assessment Form
To be filled out if I am treating you with an open insurance claim. Especially L&I or P.I.P.
scan0011.pdf
Adobe Acrobat document [649.6 KB]
Client Financial Policy
To be filled out and returned to me on your first visit. *Please don't forget to sign and date.
scan0004.pdf
Adobe Acrobat document [560.9 KB]
Records Release Form
To be filled out only if another party (ie: Medical Dr., chiropractor or insurance company) requests records of your massage therapy treatmet from me.
scan0009.pdf
Adobe Acrobat document [290.6 KB]
Health History Intake Form For Pregnant Women
To be filled out and returned to me if you become pregnant and continue to see me as your massage therapist throughout your pregnancy.
scan0005.pdf
Adobe Acrobat document [546.5 KB]
Cancer Intake Form
To be filled out and returned to me if you are diagnosed with having cancer and continue to see me as your massage therapist durring your treatment. *Or if you have recently recovered.
scan0006.pdf
Adobe Acrobat document [581.7 KB]