Rolfing Associates of the Triad APPLICATION AND CONSENT Structural Integration
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- Megan Bryan
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1 APPLICATION AND CONSENT Structural Integration I fully understand the purpose of structural integration is to balance and align the physical body so that it is supported and maintained by gravity in three-dimensional space. This is done through direct manipulation and education so that greater economy and freedom of body movement are achieved. I understand structural integration is not involved with the treatment of disease of any kind, nor does it substitute for medical diagnosis or treatment when such attention is needed. The Rolfer does not treat, prescribe, or diagnose an illness, disease, or any other physical or mental disorder of the person. Nothing done or said by a Rolfer should be misconstrued to be such. I understand it is necessary for the Rolfer to touch my body in order to assist me in establishing balance and alignment in the body. I give Rolfing Associates my permission and consent to do all those things necessary in helping me establish balance and alignment, including but not limited to touching my body. I give the Rolfer full privilege and license to work on my body in such a way to restore and establish balance and alignment therein. Furthermore, I understand that any relief of physical or emotional symptoms is coincidental in the organization of the total human being and is not the basic goal of structural integration. Date: Applicant s Signature Rolfing is a registered service mark of the Rolf Institute of structural integration. GSI is a service mark for the Guild for Structural Integration.
2 HEALTH QUESTIONNAIRE Name Referred By Address City Zip Phone (wk) (hm) Cell Occupation DOB / / Height Weight Age Do you have or have you ever had any of the following? Check those that apply: Heart Condition Whiplash Cancer Chiropractic care Convulsions Scoliosis Phlebitis or hemophilia Orthopedic braces or shoes Pregnancy or abortion Degenerative joint disease Kidney or urinary problems Hernias Ulcer or digestive disorder Osteoporosis or osteomylitis Thyroid problems Surgical pins/plates Diabetes T.M.J. syndrome High or low blood pressure Cosmetic surgery Respiratory disorder Chronic or recurrent pain Sinus problems Headaches Hepatitis Arthritis HIV Fibromyalgia Please describe any broken bones or major sprains: Describe any major injuries, illnesses, or accidents: List any surgeries that you ve had:
3 List any medications you have taken during the last six months: Are you being treated by a medical or chiropractic doctor? For what condition? Are you currently in psychological therapy? Have you ever been physically or sexually abused, or mugged? Where do you hurt? Are you pregnant? Do you have an I.U.D.? Are there any activities from which you are restricted? What kind of exercise do you do regularly? How many hours per week? Are you or have you ever been involved in any self-improvement programs (yoga, est, Silva, tai chi, holistic health classes, therapy, counseling, Landmark Education, etc)? What other types of bodywork have you had? How frequently? What would you like to receive from these Rolfing sessions? CANCELLATION POLICY Due to the large amount of time that must be blocked out for each appointment, it is necessary to require 24 hours notice of all cancellations, or the full fee will be charged. I certify that the above stated information is true and accurate to the best of my knowledge. I agree to keep my appointments in a timely manner. Signature
4 NEW CANCELLATION POLICY EFFECTIVE IMMEDIATELLY I understand that by scheduling an appointment with Rolfing Associates of the Triad, I am entering into a contract to appear at a mutually agreed upon time. The time is reserved for me. If anyone else asks for that time they will be denied it. If I cancel my appointment, Rolfing Associates may or may not be able to fill the time slot, depending on the amount of notice given. Any appointment missed or cancelled, for any reason, with less than four (4) hours notice will be charged the FULL fee. Any appointment cancelled, for any reason, with more than four (4) hours, but less than twenty-four (24) hours notice will be charged a $45 fee. We may or may not give you a courtesy call to remind you of your appointment. Your agreement to keep your appointment is not contingent upon our reminding you. I have read the above and understand and accept the conditions described. Signed: Date:
5 Rolfing Associates of Triad 515 College Rd. Suite 16 Greensboro, NC Office Policy Please keep for your records Payment is due at the time the service is rendered. We accept cash, checks, and credit cards. Our returned check fee is $20. We have found it impossible to run our office without an enforceable cancellation policy. A copy of the cancellation policy is below. This policy is as generous as we can make it. Session length is approximately 60 minutes. Please be prompt. Traditional dress for men during your Rolfing session is either a pair of briefs or running shorts. Boxers, biking shorts, long gym shorts, or shorts with zippers or pockets are difficult to work with and are not recommended. We have running shorts to loan you if needed. Traditional dress for women during your Rolfing session is underpants and bra or running shorts and a bra or tube top. Sports bras or bras with racer backs are difficult to work with; biking shorts, long gym shorts, or shorts with zippers or pockets are difficult to work with and are nor recommended. We have loaners available. Thank you for your patronage. If at any time you have questions about Rolfing structural integration, please call. We are committed to both your health and well-being and your satisfaction as a customer of Rolfing Associates of the Triad. Cancellation Policy Please retain for your records Any appointment missed or cancelled, for any reason, with less than four (4) hours notice will be charged the FULL fee. Any appointment cancelled, for any reason, with more than four (4) hours, but less than twenty-four (24) hours will be charged a $45 fee. We may or may not give you a courtesy call to remind you of your appointment. Your agreement to keep your appointment is not contingent upon our reminding you.
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TERMS OF ACCEPTANCE When a patient seeks chiropractic care and we accept such a patient for care, it is essential for both to be working towards the same objective. Chiropractic has only one goal. It is
CompassionMassage.com. Client Intake Form
Name: Phone: ( CompassionMassage.com Client Intake Form ) E-Mail: Address: _ City: State: Zip: Date of Birth: Occupation: Referred by: In case of emergency: Phone: ( Chiropractor: ) General & Medical Information:
LUCAS CHIROPRACTIC 903 Howard St. Walla Walla WA PATIENT INTAKE - update
LUCAS CHIROPRACTIC 903 Howard St. Walla Walla WA 99362 PATIENT INTAKE - update Name Today s Date / / Date of Birth / / Address City State Zip Please check box for preferred communication means E-Mail Home
FORMS 1) PAR Q & YOU:
Personal Training New Client Registration Congratulations on taking the first step to healthier and better you! The certified trainers are screened by the Vanderbilt Recreation & Wellness Center (the Rec)
WELCOME
WELCOME Thank you for choosing our office for your chiropractic care. We at Columbia County Chiropractic Center, LLC strive to provide excellent care to all of our patients, and so in that endeavor, we
Dear Prospective UMD Teen PEERS Parents:
Dear Prospective UMD Teen PEERS Parents: Thank you for your request to be a part of our University of Maryland Teen PEERS program at the Department of Hearing and Speech Clinic. Before we can schedule