*The information herein does not replace medical advice
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- Roxanne Barber
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1 *The information herein does not replace medical advice Private Massage Consent Form Massage therapy for a child is not intended to replace other forms of healthcare. Used as a form of adjunctive healthcare, potential benefits for the child include: Skeletal: - Aids in supporting good posture and balance - Reduces muscle tension that could lead to potential medical problems - Increases nutrient flow to bones Muscular: - Relieves muscle tension and spasm - Aids in removal of lactic acid & carbonic acid - Increases the flow of blood and nutrients to muscles - Can increase or decrease muscle tone depending upon amount of pressure - Can reduce or increase joint mobility depending upon amount of pressure Digestive: - May relieve constipation - May relieve gas - Reduces water retention Cleans the blood by toning the kidneys Circulatory: - Stimulates blood and lymph circulation - Helps strengthen the immune system - Releases toxins held in the body Respiratory: - Improves breathing patterns - Helps reduce respiratory problems - Relieves tension in the chest allowing the lungs to expand more fully Nervous: - Relaxes and calms - Improves sleep patterns - Raises endorphin levels, promoting healing - Provides a safe and easy release from frustration and hyperactive behavior - The Vagus Nerve is stimulated influencing food absorption hormones (Insulin & Glycogen) Child s Name: Birthdate: Caregiver s Name : Address: City: State: Zip:
2 Phone: Cell/Pgr: Referred By: In case of emergency. Name: Phone: My healthcare provider is: Phone: Contraindications for Pediatric Massage include: Fever/Temperature Acute infection, staph infection, illness or disease Skin disorder/condition which may be contagious or cause inflammation (fungus, rashes, herpes) Open sores, wounds or lesions Recent immunization/vaccination (wait hours) Life threatening medical condition Unhealed umbilical cord (tummy massage contraindicated) Swollen lymph nodes Blood clots or a blood condition Diarrhea or other sickness Inflammation High Blood Pressure Hernia Osteoporosis Varicose Veins Broken Bones Deep Vein Thrombosis Pain Lability Thrombocytopenia Common Precautions for Pediatric Massage include: Apnea Bradycardia Tachycardia Abdominal Distention
3 Gastrointestinal or Jejunostomy feeding tubes Hydrocephalus Inflammations Edema Dysplasia Hemophilia Jaundice Recent Surgery HIV/AIDS Tumors Cancer Seizure Disorders Agitation Impulsivity Please indicate any of the high risk factors, complications that I should be aware of: Is there other relevant information about the pregnancy, child birth, about you or the child, that I should know? I,, understand that my child will be participating in pediatric massage therapy as a form of adjunct health care. I have noted above all complications, risks, or conditions my child has experienced AND I have obtained my child s healthcare providers release. I understand that my child will receive pediatric massage therapy as a form of adjunctive health care only and that it is not a substitute for other healthcare provided by a medical doctor or other licensed provider. I hereby release and hold harmless and defend the practitioner from any claims, liability, demands and causes of action from my and my child s participation in this therapy. Signature: Date: Print Name: Practitioner s Signature: Date: Print Name: Practitioner s Contact Information: Audrey Arbuckle, LMT, CPMT, CIMI Loving Hands On Wheels lovinghandsonwheels@gmail.com
4 Healthcare Provider Release for Pediatric Massage Therapy To: Child s Healthcare Provider(s) Re: Release for Pediatric Massage Therapy Your Patient s caregiver,, has requested pediatric massage therapy for your patient,. This therapy is to be provided by a certified practitioner (certification requires completion of a program of massage therapy or other professional healthcare certification, and an additional comprehensive hands on training program). It is our policy to provide pediatric massage therapy only if the child s healthcare provider has reviewed this request with the caregiver. In addition, if the child has any high risk considerations, has experienced any healthcare complications or has any contraindicated conditions, we require a written release from the child s healthcare provider stating any specific limitations or precautions that you feel to be appropriate. Please verify your clearance of this request by your signature below. This verification can be modified or withdrawn at any time should your patient s health status change. Thank you for your time and assistance. Child s healthcare status is: (please circle one) normal progression special considerations (detail below) Specific limitations or precautions: You may contact me directly for clarification or concerns regarding this patient. Yes / No Healthcare Provider Contact Information: Name: (please print) Phone: Signature: Date: Practitioner Contact Information: Audrey Arbuckle, LMT,CPMT, CIMI Loving Hands On Wheels lovinghandsonwheels@gmail.com
5 Healthcare Environment Medical Consent Form This consent form below would be used by a member of the healthcare team to obtain parental/caregiver consent after they have received physician consent. Documentation of Consent for Pediatric Massage Therapy I, (print name), spoke to the parent/guardian of (in person / on the phone) about Pediatric Massage Therapy. I informed them that this is treatment has been cleared by the child s physician. I discussed risks and benefits of massage. Benefits include relaxation, pain relief and comfort. Risks include allergy to massage oil/lotion(list type), emotional release related to relaxation, and musculoskeletal soreness. Opportunity was given for them to ask any questions and these questions were answered. Questions asked: The use of an interpreter was required? Yes No The parent/guardian stated understanding of this intervention and gave permission for Massage. Signatures Person obtaining consent: Interpreter: Date/time: Parent/guardian: Witness: Date/time:
6 Massage Therapist Treatment Note Pt name: MR# DOB Diagnosis: Date Time Session started: Time ended: Time spent with family/no massage given: Referral form checked for: () Allergies () Informed consent done () Assent obtained for patient 7yrs and older who is able to assent Hand washing done prior to treatment Personal protective equipment applied () Gloves () Mask () Gown () Other Permission of patient to touch today obtained () Verbal () Gesture () Tactile Duration of patient contact: Description of massage treatment: Position(s) Prone Held Supine Sidelying Sitting Present during session Parent Nurse Other family members Other: Patient Response: Concerns/Comments: Plan: Massage Therapist Name(print): Signature:
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New Patient Information & Consents
New Patient Information & Consents Name: DOB: SSN: Gender: Address: City: State: Zip: Home #: Cell #: Other#: Employment Status: Occupation: Email Address: Marital Status: S M D W How did you hear about
natural pain relief sprains cramps injuries tensions aches
natural pain relief sprains cramps injuries tensions aches Why choose Therapacks? Therapacks are Australian-made hot and cold packs, approved by the Therapeutic Goods Administration. Therapacks have been
National Occupational Standards
What this unit is about This unit is about the skills involved in providing head and body massage treatments. It covers manual massage of the head and body, as well as mechanical body massage techniques.
Patient Name: Date: Address City State Zip Code. H. Phone W. Phone Cell Phone
Patient Name: Date: Address City State Zip Code H. Phone W. Phone Cell Phone Email Address: Sex M F Marital Status M S D W Date of Birth Age SS# Occupation Employer Referred by: Have you ever received
insurance information
patient information Last Name: First Name: MI: Date of Birth: / / (MM / DD / YYYY) Marital Status: single married other Sex: male female Home Address: City: State: Zip Code: Mailing Address (if different
Welcome to the Healthplex!
Welcome to the Healthplex! Program Please check program that applies to you. If unsure, please ask our staff. Aftercare Employee Health Pulmonary Rehab Lung Gym Cardiac Rehab Health Improvement Prenatal/Post-Partum