Client Intake Form

PLEASE READ CAREFULLY

I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during the session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment. I understand that massage therapists 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 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 massage therapist updated as to any changes in my medical profile during the session and understand that there shall be no liability on the massage therapist's part should I fail to do so. I understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session. I also understand that the License Massage Therapist reserves the right to refuse to perform massage on anyone whom he/she deems to have a condition for which massage is contraindicated.

Please note: We require A minimum of 24 hours notice to move, change or cancel any treatment that is scheduled. Otherwise there is a $35 cancellation fee applied and must be paid before receiving any other treatment from any of our staff.

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HOW DIRECT BILLING WORKS…

After providing us with your policy number/ID, we will submit your treatment claim through the online insurance portal. Ideally, the online portal will provide us with the exact amount that your benefit plan will pay; you will be required to cover the remaining portion of the visit that is not covered or confirmed by your insurance company, if anything. If, for some reason, the insurance portal is down, you will be billed the full amount of the treatment and will be required to submit your claim manually to your insurance company. Despite our best efforts, we cannot guarantee direct billing at every appointment. Factors that could affect direct billing availability include: individual insurance plan attributes, problems with the submission portal, or clinic administration considerations. PLEASE BRING AN ALTERNATE MEANS OF PAYMENT IN THE CASE THAT DIRECT BILLING IS UNAVAILABLE AT THE TIME OF YOUR TREATMENT.** Thank you in advance for your patience with the direct billing process. Our intent is to provide a seamless and convenient process. ALL our RMT's are able to Direct Bill to 24+ Insurance Companies on your behalf (in the Clinic) Some conditions apply. We are not able to direct bill for any CMT's.


A friendly reminder that we are not responsible for the outcome.