You can sign up for massage therapy with massage intake form template and you can create a hipaa compliant. Client intake questionnaire please fill in the information below and bring it with you to your first session. Proper draping will be used throughout the massage. This is the common type of massage intake form that can be provided to all massage clients. Ive also benefitted from the free intake forms and things.
It is recommended that i see a physician for any physical aliment that i may have. Oncology massage intake form must accompany a complete. Massage therapy has numerous benefits for many health conditions. Generally, therapists require patients to fill out the massage intake form before their appointment. Protect yourself, your clients and your massage therapy practice by utilizing proper documentation techniques. Massage experience have you ever had a massage before today. Also known as client intake form, a massage intake form is a way by which therapists record patient contact information, specify policies, and get an idea of the. Mental health intake form all information on this form is strictly confidential patient first name. Patient intake form pdf new patient forms massage therapy intake form acupuntura. Massage therapy is not a substitute for medical examination and diagnosis. I understand that essential oils and aromatherapy is a complementary. Massage tips, massage benefits, massage techniques, massage therapy, massage room, foot massage, massage intake forms, massage pictures, chakras reiki wenmink massage business nursing notes nursing tips nursing programs lpn programs certificate programs nursing career spine health medical technology computer science. I affirm that i have notified my therapist of all known medical conditions and injuries. Zen shiatsu therapy intake form mind body and flow.
The therapist will massage the necessary body parts to facilitate the massage excluding any contraindicated areas. Because massage may be contraindicated for specific medical conditions, i hereby release the massage therapist from any liability if i should intentionally or unintentionally omit information regarding any medical condition that i may have. Current symptoms checklist please check all appropriate columns. Pregnancy massage client intake form 1 massage therapy. New patients new patients, prior to your first massage appointment, please print out the patient intake forms, complete the forms at your convenience, then bring them with you to your appointment. Name phone day phone eve address citystatezip email date of birth occupation emergency contact phone the following information will be used to help plan safe and effective massage sessions.
Medical history in order to plan a massage session that is safe and effective, i need some general information about your medical history. We support a wide range of question formats, including body diagrams. I have completed this health form to the best of my. The following information will be used to help plan safe and effective massage sessions. This is the reason why massage centers and sessions are available in order for people to have a quiet and stressfree time for themselves. Please list current medications, including aspirin, herbs. The form is intended as an assessment tool only and serves as a guide for the applica on of massage not for medical treatment or medical assessment. Client intake form use a client intake form to fully understand your client before you begin your first massage session. Thank you for scheduling your massage therapy appointment with us, we look forward to working with you. Therapeutic massage and manual lymphatic drainage intake. To save time the day of your session, please take a moment to fill out the. Massage therapy appointments are currently unavailable. Since the therapy intake form will gather the personal information of the client, it is significant that the therapist has acquired the clients legal consent to use all the statements and details that the client disclosed in the form. Zen shiatsu therapy intake form all information is kept strictly confidential informed consent to shiatsu therapy it is my choice to receive shiatsu therapy.
The massage therapist will not perform breast massage on female clients without the written consent of the client elements does not perform breast massage. If more information is needed for treatment purposes, your therapist will ask during subsequent sessions. I understand that although massage therapy can be very therapeutic, relaxing and reduce muscular tension, it is not a substitute for medical examination, diagnosis and treatment. If you have any health concerns regarding your animal, you should consult a licensed veterinarian as soon as possible. I understand that massage therapy is given for the purposes of stress reduction, increased circulation and relief from muscular.
Recommended best practices for massage therapy the following requirements found in the most recently issued directed health measures dhm must be followed at all times if a massage therapy facility is to reopen. Spring into action against allergies massage therapy. There is also a link below to download a pdf version of our intake form which can be printed out, filled in and brought to your first session. An informed consent and waiver form should also be enclosed with the therapy intake form to assure that the. Feel free to ask any question about the information being requested. Explore the massagehealth connection and see how you can help your clients with a variety of medical challenges. I agree to keep the therapist updated as to any changes in my medical profile and. I understand that massage therapy is given for the purposes of stress reduction, increased circulation and relief from muscular paintension. Simply learning to utilize an intake form can be the positive change you are looking for to. The form has four sections namely the client information section, session information section, previous history section, and an acknowledgment section. Therapeutic massage and manual lymphatic drainage intake form. Ive also benefitted from the free intake forms and things like that which you put out there. Also known as client intake form, a massage intake form is a way by which therapists record patient contact information, specify policies, and get an idea of the patients issues, medications, and contraindications.
New patient massage intake forms boulder therapeutics. Make sure massage clients are healthy before their spa appointment. I have listed below any limitations in massage procedures for this patient. Per texas law, therapeutic massage on an animal is required to be done under the direct or general supervision of a. Please use one of the drawings on the following pages to indicate areas of discomfort or unusual sensations that you experience. It was exactly what i needed and then somei signed up. I have also informed the therapist of all medical conditions and understand that some medical conditions are contraindicated for massage therapy. Therapeutic massage would, in my opinion, be an acceptable form of adjunctive care during her pregnancy.
Coronavirus intake form for massage therapy form template. Because massage and bodywork therapy may be contraindicated due to certain medical conditions, i affirm that i have informed the therapist of all known medical. As massage is a therapy, the therapist providing the massage requires clients to complete a massage intake form. Keep track of your massage clients condition and progress with sample soap notes. Massage therapy client intake form template jotform. Name phone day phone eve address citystatezip email date of birth occupation emergency contact phone the following. New patients new patients, prior to your first massage appointment, please print out the patient intake forms, complete the forms at your. This is a therapeutic massage and any sexual remarks or advances will terminate the session and i will be liable for payment of the scheduled treatment. Since the therapy intake form will gather the personal information of the client, it is significant that the therapist has acquired the clients legal. Also, client intake form massage is used by chiropractors. Client intake form therapeutic massage webster muscular. Please list current medications, including aspirin, herbs, supplements, etc. Massage client intake form general and medical information.
Bellman, lmt, bs healing arts of ohio, 185 wapakfryburg rd, wapakoneta, oh 45895. I understand that bodywork is a health aid and does not take the place of a physicians care. The form has four sections namely the client information section, session information section, previous history. A referral from your primary care provider may be required prior to service being provided. Use amtas client intake forms to fully understand your client before you begin your first massage session. The detailed forms provided below can be downloaded and printed so they may be completed prior to your appointment. I understand that massage therapy is a therapeutic health aide and is nonsexual. Since the therapy intake form will gather the personal information of the client, it is significant that the therapist has acquired the clients legal consent to. I understand that the massage therapist does not diagnose illness, disease or any other physical or mental conditions, nor. Elizabeth bosse, licensed massage therapist and energy. Cupping therapies are adaptation of an ancient technique and possess the benefits of traditional use. I have completed this health form to the best of my knowledge.
Nov 28, 2018 21 posts related to client intake form massage therapy template. Do you have any difficulty lying on your front, back, or side. Client waiver form please take a moment to read the following statements. The therapist will not work the breast area without written consent by the client.
I understand that if the massage therapist starts a session late, she will make it. I am aware of the benefi ts and risks of massage and give my consent for massage. I have completed this form to the best of my ability and knowledge and agree to inform my reflexologist if any of the above information changes at any time. Keep track of your massage clients conditions and progress by using our free soap notes form. Client intake form therapeutic massage personal information. If at any time the client is uncomfortable with the massage, the therapist will. I further understand that massage or bodywork should not be construed as a substitute for medical examina tion, diagnosis, or treatment and that i should see a. Please answer the questions to the best of your knowledge. Copper rain does not perform any massage without proper draping. I understand that the massage bodywork i receive is provided for the basic purpose of relaxation and relief of muscular tension. Prenatal massage therapy intake form confidential information todays date name date of birth address. Use amtas client intake forms to fully understand your client before you begin your first. Because massage may be contraindicated for specific medical conditions, i hereby release the massage therapist from. Client intake form massage therapy greeley colorado.
There is also a link below to download a pdf version of our intake form which can be printed out, filled. These services are not a substitute for medical or veterinary care. Massage therapy intake contains different questions about personal information, contact information, history of pathology and the clients symptoms. With the form, the massage therapy center can collect the basic data and the medical details of the. Screen out coronavirus with your massage therapy intake form. I use a variety of techniques throughout my massages, based on what i find is going on in the tissue. Underline past conditions check here if explanation below. Neuromuscular massage therapy client intake form template. I just want to say, ive benefitted from your open, honest and nononsense approach to running a massage practice. Because massage should not be performed under certain medical conditions, i affirm that i have stated all my known medical conditions, and answered all questions honestly. These include swedish, deep tissue, trigger point, sports, prenatal, massage for relaxation and relief of muscle pain. Therapeutic massage client intake form the information request below assists us in treating you safely.
Payment policy i, the undersigned, understand and agree to the payment policy. Patient registration forms are used to register patients for procedures offered at medical facilities. Sprains or strains have you had a professional massage before. A massage therapy intake form is a powerful means of building trust in the therapeutic relationship. I, being the authorized agent or owner of this horse, have read and understand the information on this form.