Massage & Body Therapy
 

TM

CONFIDENTIAL HEALTH HISTORY
Treatment Policy & Consent Form

NAME:                                                            Date:                                       
address:                                                                                                         City:                                                                           Zip:                                
Phones:                                                     Email:                                         
Occupation:                                           Referred by:                               
Emergency contact:                                                                                  
Physician’s Name, Phone & Office Location:
                                                                                                                        
1.     What is the primary reason for your visit? 

2.     Past / present diagnosed conditions: (please explain below)

3.     Explain any current / unlisted condition, injury or surgery:
 

4.     List current medications / supplements:
 

5.     List any known allergies to nuts, oils, fragrances, etc.:
 

I understand that massage / bodywork is provided for the basic purpose of relaxation and relief of muscular tension.  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 understand that massage / bodywork practitioners are not qualified to perform skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness and that I should see a qualified medical specialist for any ailment of that I am aware.  I further understand that massage / bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that nothing said in the course of the session should be construed as such.  Because massage / bodywork should not be performed under certain circumstances, I affirm that I have stated all known health 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 responsible for full payment of the scheduled appointment.  Therapist and / or management reserve the right to refuse service or terminate treatment at their discretion. 

I am aware that payment in the form of cash or check (payable to “Tanya Meyer”) is expected at the time services are rendered.  All checks returned will be assessed a fee of $25.00.  The client understands and agrees to pay a monthly service charge of 1.5% (per annum), should any portion of the balance exceed 30 days or more. The client further agrees to pay any additional indebtedness on this account including, but not limited to, collection costs and attorney fees.  I understand that my appointment is for a specified allotment of time and failure to make the scheduled appointment on time will result in a shortened treatment session with full payment expected.  Tardiness of more than 15 minutes will be expected to reschedule.  Failing to show for a scheduled appointment or cancelling with less than 24-hour notice may result in a $30 cancellation / no-show charge billed to the client.  Any information you provide is kept in confidence.  
Check here if you do not want to receive periodic mailings from me. (   )

 I have read and agree to the above policy and consent to treatment.

  Signature                                                                Date                            
                        (Parent / Guardian Signature if Under 18)

Better Body Solutions TM
1324 E. Ogden Ave., Ste. 100
Naperville, IL  60563

(630) 963-1423

Send e-mail to [email protected] with questions or comments.
Last modified: 09/27/03