Massage/Skin Massage/Skin Step 1 of 4 25% Personal InformationName First Last SexSelectMaleFemaleBirth Date MM DD YYYY HeightWeightAddressCityStateZipHome PhoneEmail Address OccupationEmployerMailing ListYesNoHow did you hear about these services?Have you had a massage before? If yes, how many?Do you have any past experience that would make you feel uncomfortable or have difficulty with massage?If yes, please explain or privately confer with the therapist.Are there any aspects of your life that are particularly stressful?JobHabitsDietFamily/ChildrenpostureOther/Explain?Are there any areas where you seem to hold a lot of tension or any areas you would like to have extra time spent?Medical InformationAre you under a Physicians care? if, yes, please explainAre you taking any medications or supplements? if, yes, please listDo you wear contacts?YesNoDo you have, or have you had within the last two years, any of the following conditions? Allergies Diabetes Traumatic accidents or broken bones? Skin condtions Arthritis High Blood Pressure Hear Problems Spinal Problems Blood Clots Low Blood Pressure Inflamed/Swollen Joints Tuberculosis Cancer/Malignancy Have you had any surgeries? Injury/Abrasion to the skin Other Varicose Veins Please explain & date any yes answers belowDo we have permission to contact your doctor, chiropractor ot other practitioner?YesNoPhysicianPhoneAre you Pregnant?YesNoDo you think you may be?YesNoActivities/Sports/ExerciseHow often?Have you traveled anywhere in the last 6 months? If so where?YesNoOrganized Sports?YesNoWhich ?Do you have any upcoming events?YesNoWhen ?Exercise - Weights, Walking, biking, etc. ?How often?I understand the massage services which I receive are designed to be a Health Aid and are in no way to take the place of a Doctor's Care when such care is indicated. I understand that massage therapists do not perform spinal or skeletal adjustments, diagnose illness, disease or any physical or mental disorders, prescribe pharmaceuticals and that nothing said during the session(s) should be constructed as such. If I have a specific medical condition or specific symptoms for which massage may be contraindicated, a referral from my primary care provider may be required before services are provided. I take full and unqualified responsibility to keep the therapist updated as to any changes in my medical profile, and understand and agree that there shall be no liability on the therapist part should I fail to do so. If i experience any pain or discomfort during the session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort, Inappropriate actions or language in cause for termination of a treatment and the client will be responsible for payment of the appointment in full. We reserve the right to refuse service to anyone.State Law requires the following acknowledgments: The Massage Therapist is required to have an initial consultation and discuss the type of massage anticipated using, the parts of the body to be massaged or avoided, including indications and contraindications (should not be done).Therapist SignatureClientI understand I will be draped during the massage and the Therapist may not engage in breast massage without written consent of the client. The Therapist may massage the chest muscles, but if you want the breasts included in your massage initial yes below. Why massage the breasts? "promoted as a cancer preventive to prevent adhesions after implant surgery promote lactation in nursing mothers therapeutic lymphatic massage to deal with breast discomfort, dysfunction, trauma and decease." -Massage Today Sept. 2001.Client's Initial YES NO I understand if I am uncomfortable for any reason I may terminate/cease the massage session and the therapist is required to end the session.Client's InitialBecause massage is contraindicated (should not be massaged) under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. If this is for a Minor; then as parent or guardian I hereby give permission for massage services for the person listed on this form.Patient or Guardian Signature Please mention below any areas of special concern PATIENT CONSENT AUTHORIZATION CONSENT FOR TREATMENT: I voluntarily consent to the rendering of care, including treatment and performance of diagnostic procedures I understand that I am under the care and supervision of the attending physician and it is the responsibility of the staff to carry out the instructions of such physicians. RELEASE OF INFORMATION: By signing the form, you are granting consent to BODY BALANCE CHIROPRACTIC & WELLNESS CENTER to use and disclose your protected health information for the purposes of treatment, payment and health care operations. Our Notice of Privacy Practices provides more detailed information about how we may use and disclose this protected health information. You have a legal right to review OUf Notice of Privacy Practices before you sign this consent, and we encourage you to read it in full. Our notice of Privacy Practices is subject to change. If we change our notice you may obtain a copy of the revised notice by telephoning our office at 281-890-5599. You have a right to request us to restrict how we use and disclose your protected health information for the purposes of treatment, payment or health care operations. We are not required by law to grant your request. However, if we do decide to grant your request, we are bound by our agreement. You have the right to revoke this consent in writing, except to the extent we already have used or disclosed your protected health information in reliance on your consent. MEDICARE AND MEDICAID CONSENT TO RELEASE INFORMATION: I certify that the information given by me in applying for payment under Title XVIII and/or Title XI of the Social Security Act is correct, I authorize my holder of medical or other information about me, to release to the Social Security Administration or its intermediary carriers, any information needed for this or related Medicare or Medicaid claim. INFORMED CONSENT TO PARTICIPATE IN ACTIVE REHABILITATIONTHE GOALS OF TIlE REHABILITATION PROGRAM INCLUDE:I. Determining the cause and extent of your problem, 2. Providing a therapeutic exercise program to strengthen you, increase your cardiovascular endurance, range of motion and flexibility, and decrease your pain. 3. Return your to full-duty, non-restricted work status and lifestyle. THE EQUIPMENT USED TO TEST YOU AND TIlE PROCESS WE WILL BE USING WILL BE EXPLAINED TO YOU: Your participation in the rehabilitation program is voluntary. You can stop at any point in the program. Should you stop your program, we are obligated to notify your doctor, insurance company, attorney, and DVR manager, if it is applicable. If at any point during the evaluation or rehabilitation process you have any questions, we will answer them to the best of our ability or refer you to someone more qualified. Please be advised that there are no guarantees that your personal goals and orthose listed above will be met to your satisfaction. The success of any rehabilitation process lies in the combined effort of you and your provider. The "team" approach has the best chance of attaining your goals, so please ask as many questions as necessary for you to gain the maximum benefit from your rehabilitation program. Since the process of strengthening and conditioning are a form of "controlled strain", there is a chance of aggravation or injury. It is therefore imperative that you communicate to your provider any aggravation or injury that you may observe during the rehabilitation process. For example, the best exercise for you, if performed too early in your condition, may be your worst enemy if performed too soon. Communication with your provider will help put into perspective problems that may occur. Failure to discuss problems may only foster additional problems down the road. Research concerning the rehabilitation program and results may be conducted. Data will be used from the participant's evaluations and exercise program. No names will be used and all information is strictly confidential. Chiropractic as well as all other health profession. is associated with potential risks in the delivery of treatment. Therefore it is necessary to inform the patient of such risks prior to initiating care. While Chiropractic treatment is remarkably safe, you need to be informed about the potential risks related to your care to allow you to be fully informed before consenting to treatment. Chiropractic is a system of health care delivery and therefore, as with any health care delivery system, we cannot promise a cure for any symptom, condition or disease as a result of treatment in this office. An attempt to provide you with the very best care is OUT goal and if the results are not acceptable, we will refer you to another provider who we feel can further assist you. of Chiropractic treatment, as well as the least occurring; with the estimated incidence of this type of side effect 1 in 3 million upper cervical adjustment (JMPT 1996; 19; 37). Precautions such as pre-treatment history, examination, and x-ray prior to care minimize such risks, as well as performing all treatment carefully. These are not a normal and acceptable accompanying response to chiropractic care and physical therapy. Please advise your doctor if you experience any soreness, discomfort, dizziness, headache, tiredness, nausea, vomiting, loss of balance, or any other side effects or symptoms. I understand that the physician, medical personnel and other assistants will rely on statements about the patient, the patient's medical history, and other information in determining whether to perform the procedure or the course of treatment for the patient's condition and in recommending the procedure which has been explained. I understand that the practice of medicine is not an exact science and NO GUARANTEES OR ASSURANCES HAVE BEEN MADE TO ME concerning the results of any procedure. [consent to diagnostic studies, x-ray examinations, and any other treatment or courses of treatment relating to the diagnosis or procedures describe herein. By signing this form, I acknowledge that I have read or had this form read and or explained to me, that I fully understand its contents that I have been given ample opportunity to ask questions and that any question have been answered satisfactorily. All blanks or statements requiring completion were filled in and all statements I do not approve of were stricken before I signed this form. I also have received additional information including but not limited to the materials listed below, related to the procedure described herein. I hereby voluntarily request and consent to the performance of the procedures describe or referred to herein by Doctor at this facility and any other physicians or other medical personnel who may be involved in the course of my treatment. VERIFICATION OF NON-PREGNANCY (Female Patients Only):By my signature on this form I do hereby state that to the best of my knowledge, I am not pregnant, nor is pregnancy suspected or confirmed at this particular time. Date of last menstrual periodSignatureOther than Patient, Name & RelationshipWitnessInitialCAPTCHA This iframe contains the logic required to handle Ajax powered Gravity Forms.