Complementary and Alternative Health Care Client Bill of Rights for Senior Citizens (60+) 1) Practitioner s name: Jennifer N. Bierma CMT Title: Certified Massage Therapist/Owner of No Knots Professional Massage & Bodywork, Inc. Phone: 651-768-7102 Email: Jennifer@noknotsmassage.com Business Address: 445 Broadway Avenue Suite 100 St.Paul Park, MN 55071 2) Jennifer N. Bierma CMT, hereafter, the Practitioner has received the following education, training and credentials: The Practitioner graduated in 2001 from the Minnesota School of Health Sciences from a 600-hour program. There she studied Swedish massage, Integrative massage, deep tissue/trigger point therapy, reflexology, pregnancy massage, geriatric massage and infant massage. She has also received certification in Usui Reiki natural healing technique from Master Betty Lou Roy and is also certified in emergency response massage. The State of Minnesota has not adopted any educational Training standards for unlicensed complimentary and Alternative health care practitioners. This statement of Credentials is for information purposes only. Under Minnesota law, an unlicensed complementary and alternative Health care practitioner may not provide a medical diagnosis or Recommend discontinuance of medically prescribed treatments. If A client desires a diagnosis from a licensed physician, chiropractor, Or acupuncture practitioner, or services from a physician, chiropractor, Nurse, osteopath, physical therapist, dietitian, nutritionist, acupuncture Practitioner, athletic trainer, or any type of health care provider, the client May seek such services at any time. 3) If the client has a complaint or concern about the care or services they have received, the Client may also contact the Office of Unlicensed Complementary and Alternative Health Care Practice located in the Minnesota Department of Health: Mailing Address: PO Box 64882; St.Paul, MN 55164-0882 Phone: 651-201-3728 Fax: 651-201-3839 Website: www.health.state.mn.us Email: Richard.hnasko@state.mn.us 4) Practitioners fees for services in the No Knots Rejenniration room are: $55 for an hour table massage, $31 for a half hour table or chair massage and $15 for a quarter of an hour chair massage. In-home rates are: $75 for an hour table massage or $51 for a half hour table or chair massage. The above listed session fees do not include the required Minnesota state sales tax. Payment is required in full at the end of each massage session. If the Practitioner has to travel more than thirty miles, an additional $20 will be added to the Clients bill. In the case that a client fails to give 24-hour notice of cancellation, they are responsible for full payment for that session. A bill will be sent out and is to be paid in full within 15 days. If a client is 10 or more minutes late to a session, they forfeit the right to that session and are required to pay 100% of that session s fee. A bill will be sent
out and is to be paid in full within 15 days. At this time No Knots is not set up to accept insurance. Payment may be made by cash, check or credit card (Visa, MasterCard or Discover). If a check written by you or by someone you are responsible for is returned, you are required to pay the amount of that check plus an additional $40.00 fee. 5) Notice: Clients have the right to reasonable notice of any changes made to policies, services or charges. 6) The state requires a Plain language summary of the theoretical approach used to provide service to clients. The Practitioner s Theory of Treatment is: The practitioner utilizes her knowledge of human anatomy and physiology to find trigger points and muscular tension. She also uses different techniques to help increase blood and lymph circulation throughout the body to improve range of motion and mobility. 7) Notice: Clients have a right to complete and current information concerning the Practitioner s assessment and recommended service that is to be provided, including the expected duration of the service to be provided. 8) Notice: Clients may expect courteous treatment and to be free from verbal, physical, or sexual abuse by the practitioner. 9) Notice: Client records and transactions with the practitioner are confidential, unless release of these records is authorized in writing by the client, or otherwise provided by law. Under Minnesota statutes, section 144.335, subdivision 5a, a practitioner must provide written notice to clients of the possible disclosures of health records that may be made without the written consent of the patient, including the type of records and to whom the records may be disclosed. 10) Notice: Clients have a right to be allowed access to records and written information from records in accordance with Minnesota statute 144.335. 11) Notice: Other services may be available in the community. Information is available for other massage therapists in the telephone book, internet or if you want to find a massage therapists in your town/city you can contact your city hall or Chamber of Commerce and ask for that list. 12) Notice: Clients have the right to choose freely among available practitioners and to change practitioners after services have begun, within the limits of health insurance, medical assistance, or other health programs. 13) Notice: Clients have a right to coordinated transfer when there will be a change in the provider of services. 14) Notice: Clients may refuse services or treatment, unless otherwise provided by law. 15) Clients may assert the client s rights without retaliation from the Practitioner. Prior to any service, a complementary and alternative health care client must sign a written statement that they have read or received the client s bill of rights. I hereby acknowledge receipt of the Client Bill of Rights and I have had a full opportunity to ask any questions I have about this document and my rights as a client. I understand my rights as a client. Client signature Date
Health Information (Please make sure to fill out all forms front and back.) Full Name: Address: Home Phone #: ( ) - Daytime Phone #: ( ) - Cell Phone: ( ) - E-mail: Occupation: Retired? Yes No Age: Date of Birth / / Marital status: Minor Single Married Widowed Divorced Live-in Partner In Case of an Emergency contact: Name: Address: Phone #: Relation: How did you find out about No Knots? Have you received massage treatment before? How often? Never before Occasionally Every month
More than once a month Was your last massage therapy experience a pleasant one? What is the nature of your visit today? Current level of stress: (circle one) 1 2 3 4 5 low high Check any of the following that apply: Contact Lenses or glasses Dentures A hair piece Braces Prosthesis Artificial joints Amputation Pins Staples Plates Other (please explain) Check any of the following that are true for today: Sunburn Inflammation Cuts, burns, bruises Severe pain Headache Irritated skin rash Poison Ivy/Oak Cold/flu Pregnant Please Circle any areas of discomfort, especially muscle tension.
Medical History Do you smoke? (If yes, for how long? How much per day?) Do you drink alcohol? (If yes, how often?) Do you use recreational drugs? Are you on any prescribed medications? (Please describe medication and it s purpose.) Are you allergic to any lotions, oils, materials or scents? (Please describe) Have you had any major surgeries? (If so, what was it for and when was it?) Have you been in any automobile accidents? (If so, When and did it have any effect on you?) Have you been hospitalized in the past 2 years? (If so, when and why?) Please check all that apply: Aids (HIV) Abdominal Pain Heart attack Alcohol treatment program Arthritis (type?) Heart disease Asthma Athletes foot Hernia Blood disorder Breathing problems Back pain Bursitis Cancer/tumors Joint pain Chronic Fatigue syndrome Chemical dependency - range of motion + blood pressure Depression Diabetes - blood pressure Dizziness Eczema Kidney disease Glaucoma Headache Pacemaker Cerebral palsy Multiple Sclerosis
Please check all the apply (cont.): Neck pain Nervous tension Numbness Parkinson s disease Pneumonia Lung disease High cholesterol Frequent stress TMJ Bowel problems Poor circulation Rashes Seizures/tremors Post traumatic stress syndrome STD Sinus troubles Spinal/disc problems Sprains/fracture Tendonitis Thyroid disorder Tuberculosis Ulcers Vaginal infection Varicose veins Whiplash Bruise easily Sensitive to touch Shoulder pain Broken bones Because the massage therapist must be aware of any existing physical conditions that I may have, I have listed all my known medical conditions and physical limitations and I will inform my massage therapist of any changes in my physical health. I understand and agree that; 1) the massage therapy that I am given is for the purpose of stress reduction, relief from muscular tension or spasm and/or for improving circulation; 2) that a massage therapist neither diagnoses illness, disease or any other medical, physical or mental disorder, nor performs any spinal manipulations; 3) I am responsible for consulting a qualified physician for any physical ailments that I may have. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, a report to the proper authority and I will be liable for payment of the scheduled appointment. I agree that all services rendered to me are charged directly to me and I am responsible for payment unless prior arrangements have been made. I agree to pay for all scheduled appointments that I am unable to keep unless I notify my therapist at least 24-hours in advance. I also agree that in the case that I am ten or more minutes late I forfeit the right to the massage session for that day and pay 100% of the fee for that session. Signature: Date: