Name: __________________________________________________       Date of Birth: _________________________________

Street Address: _____________________________________________________________________________________________

City: ________________________________________________    State: __________    Zip Code:_________________________

Home Phone: _____________________________________    Cell Phone: ___________________________________________

Email Address: _____________________________________________________________________________________________

 

Emergency Contact: _____________________________    Phone: ________________________________

Relationship to Patient/Client: ______________________________________________________________

Primary Care Doctor: _____________________________   Phone:_________________________________

Specialist Doctor:________________________________    Phone:_________________________________

 

How did you hear about massage at Magna Physical Therapy? ________________________________

 

MASSAGE POLICIES:

• It is our policy that services be paid for at the time of or before services are rendered. Payments are non-refundable.

• Magna Physical Therapy will accept the following forms of payment for services provided: cash, personal check, credit or debit card (Visa, MasterCard, and Discover).

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If you are unable to keep your scheduled appointment, we kindly ask that you call our office to cancel or reschedule 24 hours in advance. If an appointment is cancelled or rescheduled without at least 24 hour notification, a charge will be applied for the full price of your scheduled massage.

 

I, the undersigned, have reviewed the above policies and do hereby agree to abide by them to the best of my abilities.

 

Client/Guardian Signature: _________________________________   Date: _________________________

 

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Name: ___________________________________________________   Date: _________________________

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MASSAGE RELEASE
 

By signing this, I agree that I have answered all questions to the best of my knowledge and that I will inform the therapist of any changes in my condition or medication. If I experience any pain/discomfort or would like the pressure adjusted, I will inform the therapist immediately.

I understand that a massage therapist cannot diagnose any illness, disease, or any physical or mental disorders, nor can the therapist prescribe any medication, and that nothing said in a session should be construed as such. I understand that massage therapy is intended to work in conjunction with my health care, not act as a substitute for medical examination.  I understand that it is my responsibility to consult a physician for any ailments I may have.

I understand that massage therapy is a therapeutic measure used to reduce stress, muscular tension, and pain. I understand there are no guarantees for recovery and if I am unsatisfied with the progress made with my treatment I will inform the therapist, so he/she may direct me to another treatment. I also understand that massage therapy is non-sexual in nature and any advancement made will terminate the massage.

I agree to abide by a 24 hour cancellation notice for any scheduled massage. I understand I will be charged the full amount of service for missed appointments or for any cancellations with less than a 24 hour notice. I understand that if I arrive late for an appointment, the session will end at the original scheduled time to prevent penalizing another client. However, if the massage therapist is late, he/she will fulfill the scheduled massage length or offer a reasonable compensation.

I understand that if I use a coupon during my visit, it is not valid with any other coupon or promotion.

I agree that I am of legal age (18 years old) and that if I am not, I agree to have my parent or guardian sign a parental/guardianrelease form before treatment.

I understand that certain conditions or medications may contraindicate (not permit) massage or may require the use of alternate techniques or pressure. I respect the decision of the massage therapist and am fully prepared to reschedule the massage for a later date if requested by the massage therapist. I also understand that massage may be advisable by my physician, but not by a massage therapist. In that event, I agree to provide a written agreement from my physician before proceeding with treatment.

 

Client Signature: __________________________________________________________    Date: _________________________

Practitioner Signature: ___________________________________________________    Date: _________________________

 

Consent to treatment of a minor: By my signature below, I hereby authorize____________________________ to administer massage, bodywork, to my child or dependent as they deem necessary.

Parent/Guardian Signature: _____________________________________________    Date: _________________________

 

Client/Guardian Signature: ______________________________________________    Date: _________________________

 

MPT Witness Signature: _________________________________________________    Date: _________________________