New Massage Patient Intake Form
Please fill out this form, then download the health history and complete before your appointment.
24-hour notice is required
If less than 24-hour notice is given, there will be a cancellation charge. This is not billable to your insurance and must be paid before your next appointment. The charge will be as follows:
30 min massage = $25
60 min massage = $45
90 min massage = $70
120 min massage = $90
I understand that this fee is my personal responsibility and cannot be billed to my insurance company. I understand that this courtesy reduced fee for late cancellation may only be used 3 times per call
I understand that if I am 15 minutes late for an appointment, the cancellation fee will apply, or I may elect to get the remainder of my massage at full fee if the office is notified of my intent.
Massage Therapy Informed Consent
I understand that massage therapy given here is for the purpose of pain relief, stress reduction, relief from muscular tension or spasm, or increasing circulation.
I understand that the massage therapist does not diagnose illness, disease, or any other physical or mental disorder. As such, the massage therapist does not prescribe medical treatment or pharmaceuticals, nor performs any spinal manipulations. It has been made very clear to me that massage therapy is not a substitute for medical examination and/or diagnosis and that it is recommended that I see a physician for any physical ailment that I might have.
Because the massage therapist must be aware of existing physical conditions, I have stated all my know medical conditions and take it upon myself to keep the massage therapist updated on my physical health.
Financial policy for massage therapy
If applicable, I understand that Fern Creek Chiropractic Center will file with my insurance as a courtesy for this treatment. I also understand that any changes to my policy not reported to the office leading to untimely filing could result in insurance denial of my claim. I understand that any change in my condition, claim status or liability must be reported to the office to ensure proper filing. I understand that I am ultimately liable for any fees incurred should my insurance company choose not to cover my costs.
I have read, understand, and agree to the massage therapy financial office policy.