Tranquility Massage Therapy & Reiki, LLC

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Client Contact Information Tranquility Massage Therapy & Reiki, LLC Client Name: Date: Date of Birth: Gender: Address: Phone: Email: Referred by: Emergency contact: Phone: Physician/Health-care Provider name: Phone: Is this massage/bodywork medically necessary (is it for a medical condition, injury, surgery)? Yes No Do you have a physician referral/prescription? Yes No Are you seeking insurance reimbursement? Yes No If yes, please complete the Billing Information form. Type of insurance coverage for this claim: Car Collision Worker s Compensation Private Health Massage Information Have you ever received professional massage/bodywork before? Yes No How recently? What types of massage/bodywork do you prefer? What kind of pressure do you prefer? Light Medium Firm What are your goals/expected outcomes for receiving massage/bodywork? How do you feel today? List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.): Do these symptoms interfere with your activities of daily living (e.g., sleep, exercise, work, childcare)? Yes No Explain: List the medications you currently take: Are you wearing contacts? Yes No Are you wearing a hairpiece? Yes No Are you wearing dentures? Yes No Are you pregnant? Yes No

Health History Have you had any injuries or surgeries in the past that may influence today s treatment? Circle any of the following health conditions that you currently have (If you are unsure, please ask): blood clots, infections, congestive heart failure, contagious diseases, pitted edema Please answer honestly, as massage may not be indicated for the above conditions. Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Current Past Muscle or joint pain Current Past Muscle or joint stiffness Current Past Numbness or tingling Current Past Swelling Current Past Bruise easily Current Past Sensitive to touch/pressure Current Past High/Low blood pressure Current Past Stroke, heart attack Current Past Varicose veins Current Past Shortness of breath, asthma Current Past Cancer Current Past Neurological (e.g. MS, Parkinson s, chronic pain) Current Past Epilepsy, seizures Current Past Headaches, Migraines Current Past Dizziness, ringing in the ears Current Past Digestive conditions (e.g. Crohn s, IBS) Current Past Gas, bloating, constipation Current Past Kidney disease, infection Current Past Arthritis (rheumatoid, osteoarthritis) Current Past Osteoporosis, degenerative spine/disk Current Past Scoliosis Current Past Broken bones Current Past Allergies Current Past Diabetes Current Past Endocrine/thyroid conditions Current Past Depression, anxiety Current Past Memory Loss, confusion, easily overwhelmed Current Past Lymph nodes removed - please circle YES NO When Comments: Consent for Treatment If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage/bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. Understanding all of this, I give my consent to receive care. Client Signature: Date: Parent or Guardian Signature (in case of a minor): Date:

Informed Consent Form This record of consent is required before the first assessment or treatment and will be maintained confidentially in the client file. It may only be released to a third party with prior written consent of the client. Massage Therapy includes the assessment and treatment of the soft tissues and joints of the body, using soft tissue manipulation, joint mobilization, hydrotherapy, remedial exercises and self-care programs as determined by the therapist. Treatment plans will be discussed in advanced with the client and must be agreed upon prior to start. By signing below, the client agrees to the following: All massage treatments, information and records will be kept confidential and securely stored for use only by the massage therapist. Written consent must be given by me prior to any disclosure or sharing of my personal and clinical information with any third party. I understand that privacy will be assured as I have the right to undress only to my comfort level and according to the requirements of the treatment. I freely give my permission to receive massage therapy treatments. I understand that massage is contraindicated for some medical conditions and that obtaining a medical clearance or prescription may be necessary before beginning treatment. I understand potential risks and undesirable effects of massage such as soreness, bruising, and exacerbation of symptoms. I agree to inform the therapist of any experience of pain during initial and subsequent sessions. I understand that I have the right to refuse any treatment or ask that it be modified in regard to pressure or technique. I understand that I will be draped during treatment in accordance with state laws and that I may request additional draping if desired. I agree to update the therapist on changes in my health status and understand that no liability on the therapist s part shall exist if I should neglect to do so. I understand that massage therapy does not replace or substitute medical examination/care and the therapist does not diagnose; I should see a medical physician, chiropractor or other health care provider to address concerns that are outside the scope of massage therapist s practice. I understand that promptness is expected for all appointments. In the event of lateness, I understand the following: o the massage may be cut short due to other commitments of the therapist; o the therapist may cancel/reschedule the massage appointment due to other commitments; o fees will be maintained per the schedule and are due prior to departure on the day of treatment. Cancellation of any appointment must be received at least 24 hours in advance; otherwise the full appointment fee is due. I understand the therapist may refuse to treat a local area that is a contraindication to massage. I understand that the therapist may refuse to treat a client that makes her feel unsafe or a client who makes sexual advances. I, (PRINT NAME), have read and understood the information above and consent to massage treatment for the conditions discussed with my therapist today. Client signature: Date:

Health Status Form Client Information Client Name: Date: Date of Birth: Depict how you are feeling today by drawing a circle on the figures representing the size and shape of the following symptoms. Place the letter representing the symptoms in or near the circle: P = Pain, ache, or tenderness S = Stiffness in the joint or muscle Rate how you are feeling today by drawing a circle around the number that best represents how you are doing today: No pain 0 1 2 3 4 5 6 7 8 9 10 Worst pain imaginable Able to do everything 0 1 2 3 4 5 6 7 8 9 10 Not able to do anything Comments: Is there anything else I should know about how you are feeling today or about your progress or care to date? Signature: Date:

Financial Policy Initial Intake and Treatment $80 for 60 minutes $120 for 90 minutes Follow up appointments $80 for 60 minutes $120 for 90 minutes Cash, checks and credit cards are accepted and due at the time of treatment. Cancellation Policy: All scheduled appointments require a 24 hour cancellation notice or the patient will be charged for the FULL office fee. My contact information: Claire Metzler Phone: 973.906.0815 Email: Website: clairemetzler@massagetherapy.com www.clairemetzler.massagetherapy.com Patient Signature: Print Name: Date:

Office Policies Client Information Client Name: Date: Date of Birth: Please be advised of the policies for this office. Your signature below signifies acceptance of these policies. Cancellation A 24-hour notice is required for cancellation of an appointment, or you will be charged in full for the appointment. Payment is due before your next appointment. Tardiness Appointment times are as scheduled and cannot extend beyond the stated time to accommodate late arrivals. Please be on time to your appointment. Sickness Massage/bodywork is not appropriate care for infectious or contagious illness. Please cancel your appointment as soon as you are aware of an infectious or contagious condition. If it is within the 24-hour notice period, the cancellation fee may be waived. No call/no show Policy Current credit card information is required to be on file with this office. Your credit card will only be charged for no call (see above regarding cancellations) and no show appointments. Inappropriate Behavior Policy Massage therapy is for relaxation and therapeutic purposes only. There is absolutely no sexual component to massage whatsoever. Any insinuation, joke, gesture, conversation or request will result in an immediate termination of the session and refusal of any and all services in the future. You will be charged the full session fee regardless of the length of your session. A report will be filed with the local and/or state authorities. Treat your therapist with respect and dignity and you will be treated the same in return. I, (PRINT NAME), have read and understood the information above. Client signature: Date:

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