Initial Appointment Intake Form

1. What brings you in for a massage? You may also use any of the descriptors below.

Characters: 0/255

Relaxation

Stress

Injury (see injuries section below)

Pain

Referral

4. Provide any details to best describe the QUALITY your symptom(s). You may also use any of the descriptors below.

Characters: 0/255

11. Do you have any other conditions that your massage therapist should know about?

*Please note direct billing to your health benefit plan is an option for second and future visits. Coordination of benefits for a secondary plan is not available.

Name of the insurance policy? (i.e, workplace, company, university, union, association, etc.)

Characters: 0/255

What is the policy number? (certificate number, plan number, etc.)

Characters: 0/255

What is the member ID or number? (employee number, student ID, etc.)

Characters: 0/255

Patient Consent and Disclosure Statement (Review Required)

You need to review and accept this before submitting

Massage Therapy Fee Schedule (Review Required)

You need to review and accept this before submitting

Covid-19 Consent Form (Last updated April 15, 2020) (Review Required)

You need to review and accept this before submitting