Confidential
Health Intake
All information is confidential and will not be shared or sold to anyone except as required by law.
Name______Date of Birth ______
Address______City, State, Zip______
Best phone # to reach you ______Alternate phone # ______
Email ______Occupation ______
Emergency Contact ______Phone ______
How did you hear about Sundance Massage? ______
Have you ever had a professional massage before? ___Yes ___No
Please list any allergies or sensitivity to scents ______
What kind of exercise do you get and how often? ____________
What are your common areas of pain or tension? ______
Any skin conditions, warts, eczema, athletes foot, etc.?______
Are you currently seeing a healthcare professional? ____ Yes ____ No
If yes, please list names and reason/treatment/medications: ______
______
Please indicate any conditions that you have had or currently have:
o Headaches, migraines
o Arthritis, tendonitis
o Cancer, tumors
o Abnormal skin condition
o Heart/circulatory issues
o Joint surgery
o High/low blood pressure
o Pregnancy
o Major accident
o Blood clots
o Sprains/strains
o Neck/back injuries
o Recent injuries
o Diabetes
o Fibromyalgia
o Paralysis
o Numbness/tingling
o Lack of or reduced feeling/sensation
Varicose veins
Explain any conditions that you have marked above, or anything else your therapist should know:
______
The information I have provided on this form is correct and current to the best of my knowledge. I understand that it is my responsibility to inform the massage therapist of any changes to this information. I understand that the massage therapist does not diagnose illness, disease, or any further physical or mental disorders, or prescribe medical treatment.
I understand that the massage I will be receiving here is for therapeutic purposes only, and any sexual remarks or advances will terminate the session and I will be liable for payment of the scheduled service. I understand that if I experience any unusual discomfort and/or pain during my massage sessions it is my responsibility to inform the massage therapist so that they can adjust the pressure or technique being used.
Cancellation Policy – I agree to give at least 24 hours notice to cancel or reschedule any appointment. I understand that if I do cancel or reschedule within that time for any reason, I may be charged up to 100% of the service price. I understand that if I arrive late for my appointment, the therapist may only have the original time period available to complete my massage, and I will be charged the full amount of the session.
______Client Signature Date
DIRECT BILLING INSURANCE INFORMATION
Name ______Phone ______
Address______City ______Zip ______Birth date ______
Date of Injury______Referring Dr ______
Dr Address: ______Dr. Phone: ______
Diagnosis on RX______
Conditions re: MVA: Driver? Passenger? Your Car? Other? ______Rear End? Front End? Other? ______
Work related? Job site injury? ______
Insurance Co ______Claim # ______Address______Zip ______
Adjuster ______Phone ______
Policy Holder ______Address ______
______Zip______Birth date ______
Other Insurance Company Name ______Address ______
Previous MVA? ______Previous PIP Claim open? ______Now Closed? ______
Lawyer Name (if any) ______Phone ______
Firm Address ______City & Zip ______
______
PLEASE READ THE FOLLOWING AGREEMENT AND SIGN BELOW:
When scheduling appointments, I agree to inform the receptionist that I am on direct insurance billing. I agree to abide by the parameters of the prescription my doctor has written. When I have come to the end of treatment for my injuries and am ready to close my insurance case, I agree to inform you and to check with the insurance company to make sure all bills have been submitted and paid before I close the case.
Should any fees for my massage treatments remain unpaid at the close of my case, or should any properly filed claim be denied, I agree to be responsible for and pay these fees to you. I understand the fee schedule to be: $35 per unit or $140 per hour for Injury Treatment. If I miss an appointment or cancel with less than 4 hours notice, I agree to pay the cancellation fee for the session, which is $40.
I authorize the release of all records to my insurance company, health care providers, and lawyer. I authorize you to bill for services provided. Should I employ a lawyer and seek a litigated settlement, I will inform you.
I verify that the above information I have provided on this form is correct and current.