MEDICAL MASSAGE & ACUPUNCTURE P.S.

ADMISSION FORM

I (patient/parent/guardian) agree to massage therapy, acupuncture treatment and procedures that are provided by an authorized

employee of Medical Massage & Acupuncture.

I agree to authorize all insurance benefits to pay directly to Medical Massage & Acupuncture.

I understand that Medical Massage & Acupuncture has the authority to release any information necessary to the insurance company

for the processing of medical claims.

As a courtesy, Medical Massage & Acupuncture will obtain a verification of applicable insurance benefits as they are quoted to them,

but some third party payers misquote benefits, coverage and liability. The facility & staff are not responsible for what a third party

payer and/or representative may tell them. Any contractual, written, verbal or other obligations or arrangements between me and

an attorney, insurance company, liable or third party payer are between me and said person.

I understand that my insurance policy is a contract between patient and insurance company. Medical Massage & Acupuncture is not

a party to that contract. It is my responsibility to be familiar with my insurance policy.

While Medical Massage & Acupuncture is happy to submit my claims to my insurance on my behalf, payment for medical services

provided is my responsibility. Copays are due at the time of service. I understand that I am financially responsible for all charges

that have been incurred for medical services rendered on my behalf. If my health insurance denies my medical claims, I understand I

am responsible for the cost of the massage therapy and/or acupuncture treatment. Any amounts left owing after insurance

reimbursement is made are also my responsibility.

Should my account be referred for collection, I am responsible for reasonable attorney fees and collection expenses. All delinquent

accounts bear interest at the legal rate. In the event of court action, venue and jurisdiction shall be Lewis County in the State of

Washington.

PATIENT CONSENT & SIGNATURE

Sign Here (If Minor, Parent Must Sign) Date

CANCELLATION & NO SHOW POLICY 24-HOUR CANCELLATION POLICY

Medical Massage & Acupuncture requires 24 hour notice in advance if you are unable to keep your appointment. Since we set aside

one hour for each appointment, it is only respectful of our time, as well as the time of others who wish to be seen, that you give

adequate notice. We certainly understand that extenuating circumstances can arise over which you have no control. However,

please be advised that we will charge $25.00 in the event that an appointment is missed/late cancellation. This is a charge for

which your insurance company is not responsible. Therefore, it will be billed directly to you.

I have read and understand the above policy and agree to abide by it while being treated at Medical Massage & Acupuncture.

PATIENT CONSENT & SIGNATURE

Sign Here (If minor, parent must sign) Date

MEDICAL MASSAGE & ACUPUNCTURE P.S.

DEMOGRAPHIC INFORMATION

Date: ________________________

Name: ____________________________________________________________________________________

First Middle Initial Last

Date of Birth: ______________________ Age: ___________ Sex: Female/Male

SSN: _____________________________ Marital Status: Single/Married/Divorced/Separated/Widow

Mailing Address: ___________________________________________________________________________

City: _________________________________ State: _______________________ Zip: ___________________

Physical Address: ___________________________________________________________________________

(If different then above)

Home Phone: ___________________________ Cell Phone: ________________________________________

Work Phone: ___________________________ Email: _____________________________________________

Employer: ________________________________________ Occupation: _____________________________

Employer Address: __________________________________________________________________________

Spouse/Guardian Name: _____________________________________________________________________

Phone: __________________________________ Cell: ____________________________________________

Spouse/Guardian Employer: __________________________________________________________________

Spouse/Guardian Employers Phone: ______________________________________

Emergency Contact: _________________________________________________________________________

Relationship: _______________________________ Phone: ________________________________________

Family Physician: ___________________________________________________________________________

Phone: ______________________________________

Referred By: _______________________________________________________________________________

MEDICAL MASSAGE & ACUPUNCTURE P.S.

HEALTH REPORT

PREVIOUS HISTORY

Please list injuries, falls or surgeries

Date Treatment

NAME 3 SYMPTOMS OR PROBLEM AREAS: (HEADACHES, PAIN, OR TENSION) PLEASE RATE INTENSITY ON

A SCALE OF MILD, MODERATE, OR SEVER. HOW LONG HAS THIS OCCURRED?

Symptom or Problem Area Intensity How Long?

ON FIGURES BELOW, MARK THE LOCATIONS OF THE SYMPTOMS. PLEASE LABEL IF PREVIOUS OR

CURRENT.

Name___________________________________________________ Date of Birth___________________

MEDICAL MASSAGE & ACUPUNCTURE P.S.

MASSAGE ONLY

MASSAGE CONSENT TO TREATMENT

Yes No | Have you ever received a professional massage? When: How often:

What results do you want from your session?

Is there anything else you would like your therapist to know?

I understand that massage therapists do not diagnose illness, disease, or other physical or mental disorders.

Massage therapists do not prescribe medical treatment or pharmaceuticals. It has been made clear to me that

massage is not a substitute for medical examination or diagnosis and that it is recommended that I see a

physician for any physical ailment that I might have. I have stated all my known medical conditions and take it

upon myself to keep Medical Massage & Acupuncture updated on my physical health.

Signature: _________________________________________________ Date: __________________________

MEDICAL MASSAGE & ACUPUNCTURE P.S.

MASSAGE INFORMATION AND POLICIES

If you have had a massage before, you know the benefits it can bring. If you are new to massage, you may

have some questions. Please feel free to ask us at any time. Below we have provided the answers to some

commonly asked questions and concerns.

You will be asked to disrobe to your level of comfort. If you have any reservations or concerns

regarding disrobing, please let your massage therapist know at the beginning of your appointment.

We love children; however, so that you may receive the full benefit of your massage treatment, we

discourage them being present. If this is not possible, please let us know in advance.

Massage is powerful and therapeutic. Drinking plenty of water before and after your massage is very

important. Muscles and joints need to be hydrated to prevent cramping and help eliminate the

accumulations of toxins. Water is the key to flushing these toxins from your body.

If your immune system is fighting a cold or the flu, or you are experiencing any health problems that

you feel may affect your massage, please inform you therapist before your appointment.

You may be instructed to ice specific areas after your treatment since your muscles have worked in a

new way. You may experience some stiffness or tenderness the next day. This is common, but icing will

reduce this a great deal. If tenderness lasts more than a day, let your therapist know at your next

appointment or feel free to give us a call. If your body is usually sensitive to more than a light massage,

please discuss this with your therapist. This will enable us to give you the best treatment possible for

your body.

To ensure that you receive the maximum benefit from your massage treatment we ask that you please

turn off all cellular phones during the session. If you need to leave your phone on due to possible

emergency circumstances that you need to be available for please let your therapist know.