Pam Skeele, LMT, CA Jude Painton, LMT, CA Emma Kim, LMT, CA

CHIROPRACTIC HEALING CENTER

492 E 13th Ave. Suite 200

Eugene, OR 97401

Ph: (541)342-4520 F: (541)485-7102

Laura Adams, D.C. | Marisa Aptecker, D.C.

Pam Skeele, LMT, CA | Jude Painton, LMT, CA | Emma Kim, LMT, CA

Chiropractic Healing Center | 492 E. 13th Ave. Suite 200 | Eugene, OR 97401 (541)342-4520 fax: (541)485-7102

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PATIENT REGISTRATION

Today’s Date ______

Name______Date of Birth______Age ______

Address ______Home Phone ______

City ______State_____ Zip______Cell Phone ______

F__ M__ E-mail______Occasional Newsletter OK? Y/N

Employer ______Occupation ______Work Phone ______

Marital Status: S M W D P Spouse’s Name ______# of Children ______

How did you hear about us? ______

Emergency Contact (name & phone): ______

I am here today due to: __ Illness __ Trauma __ Work Injury __ Auto Accident __Other

What date did this occur? ______

FOR INSURED PATIENTS ONLY

PRIMARY INSURANCE FOR TODAY’S VISIT: ___Private Ins. ___Auto ___WC ___Medicare

Ins. Co. & Address ______

Name of Insured: ______ID No: ______

Group No. ______Claim No. ______Medicare No. ______

SECONDARY INSURANCE: ___ Private Ins. ___ Auto ___ WC ___ Medicare

Ins. Co. & Address: ______

Name of Insured: ______ID No: ______

Group No. ______Claim No. ______Medicare No. ______

I understand that health insurance policies are an arrangement between my insurance carrier and myself. Billing is done by the Chiropractic Healing Center as a courtesy only and all services rendered to me are my personal responsibility. If my insurance company is not paying, or stops paying, I will be required to pay for massage in full at the time of service. A refund will be issued by Chiropractic Healing Center at the time payment is received from the insurance company. I authorize the release of any medical information necessary to process my insurance claim and I authorize payment of medical benefits to this office for professional services rendered.

Patient Signature______Date ______

MASSAGE CLIENT INTAKE QUESTIONNAIRE

Name______Date ______

Date of birth______Occupation ______

Referred by ______

Have you ever had a massage before? ______

Likes: Dislikes:

What would you like to get from massage (relaxation, tension relief, injury rehabilitation/prevention, etc.)?

Is there any area on which you would like extra work? Any area that is frequently tense or painful?

Any repetitive motion or stress from your job? Are you right or left-handed?

Do you participate in a sport or form of exercise? If so, what kind of activity and how often?

Are you under a physician’s care or have you recently been ill, injured, or hospitalized? If so, please explain.

Please check all that pertain to you:

__ Allergies (i.e. nut oils, fragrances, etc) / __ Fractures, tendon and/or ligament damage
__ Arthritis / __ Headaches
__ Asthma / __ Hearing devices
__ Athlete's foot / __ Heart or kidney disease
__ Blood or clotting disorders / __ Homeopathic remedy
__ Blood pressure/circulatory problems / __ Currently or possibly pregnant (__ wks)
__ Bruise easily / __ Skin conditions/rashes/diseases/cuts/sores
__ Contact lenses / __ Major surgery, trauma, or illness
__ Contagious diseases / __ Tumors or malignancies
__ Diabetes / __ Varicose veins

Do you have any medical conditions that are not mentioned above?

Are you currently taking medications? If so, please identify.

I certify that the above information is true and correct to the best of my knowledge and that I consent to receiving this massage and any further sessions.

Signature______Date ______

Cancellation Policy: We need 24 hours notice for all cancellations.

If you cancel with less than 24 hours notice you will be charged 50% of the total charge for the visit. If you fail to keep your appointment and do not cancel, you will be charged IN FULL.