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Our goal, at the Center for Bodywork Therapies, is to ensure you receive the highest quality bodywork possible.  Please take a moment to carefully read and complete the following information.

Required Information



Last Name

Last Name


First Name

First Name


Street Address

Street Address


City

City


State

State


Zip Code

Zip Code


Telephone

Telephone


E-mail Address

E-mail Address


Birthdate

Birthdate


Emergency Contact

Emergency Contact




Current Physical Condition


Are you currently under a doctor's care?

Are you currently under a doctor's care?


Doctor's Name

Doctor's Name


Doctor's Phone Number

Doctor's Phone Number


Please list all of your current medications:

Please list all of your current medications:




Expectations

What is the purpose of this appointment?

What is the purpose of this appointment?

Please choose from Injury rehabilitation | pain management | stress/anxiety management | relaxation | specify other

Please explain

Please explain


Frequency of previous bodywork:

Frequency of previous bodywork:

Choices:  Weekly | Monthly | Every few months | Occasionally | Hardly ever | Specify Other

Consent for Care

Consent for Care

I understand that my practitioner is not a licensed medical healthcare provider and that bodywork/massage is not a substitute for medical care, medication examination or diagnosis.  I have stated all my known medical conditions and will inform my practitioner of any change in health status in all services received at the Center for Bodywork Therapies.  I understand that there is no implied or stated guarantee of success or effectiveness for bodywork/massage sessions.  It is my choice to receive bodywork/massage and I give my consent for bodywork/massage.  I understand that the client/practitioner relationship will be held in strict confidentiality in accordance with all federal HIPPA regulations and that the services I receive may be provided by a third party contracted practitioner and I hold Nature's Way, Inc. and the Center for Bodywork Therapies harmless against any and all liability incurred by such third party contracted practitioner.

I understand that the massage/bodywork I receive is provided for the basic purpose of relaxation annd/or relief of muscular tension.  If I experience any pain or discomfort during a session, I will immediately inform the contractor/practitioner so that the pressure and/or strokes may be adjusted to my comfort level.  I uderstand that massage/bodywork practitioners are ot qualified to perform spinal and skeletal adjustments, diagnose, prescribe or treat any physical or mental illness and that nothing said in the course of any session I participate in should be construed as such.  I have stated all my known medical conditions and answered all questions honestly.  I agree to keep all practitioners of the Center for Bodywork Therapies updated as to any changes in my medical profile at all times and during later visits and understand 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 the immediate termination of the session, and will be liable for payment of the scheduled appointment.  I release Nature's Way, Inc., the Center for Bodywork Therapies and its contracted therapists from all claims of malpractice, non-disclosure or lack of informed consent.  I freely assume all risks of the massge whether presently contemplated or hereinafter discovered.
Cancellation/rescheduling Policy

Cancellation/rescheduling Policy

The time you schedule is reserved just for you.  I understand my treatment schedule is designed for optimal results, and missed appointments will hinder my progress.  I agree I am responsible for all payments for services and agree to give at least 48 hours notice for cancellation or rescheduling my appointments or will pay the full price of the reserved session time.
By submitting this form electronically, you agree to the terms and conditions as defined above.

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Copyright © Janet Lawlor, BCTMB