FORMS

Please fill out & submit forms prior to your first appointment
Consent Form During Covid-19 for
Myofascial Release of Berkeley

By submitting this form, you agree to have myofascial release services during the pandemic.

Client Name

By checking the boxes, you confirm that you agree with the following statements:
Do you have any of these symptoms: cough, shortness of breath, high fever, muscle pain, body ache, nausea, loss of taste/smell?
Within the past 14 days, have you been in contact with anyone that has COVID-19 symptoms or has gotten infected?
Are you living with anyone that is infected or quarantined due to COVID-19?

Office Policies

Client Information

Please be advised of the policies for this office and signature below signifies acceptance of these policies.

Cancellation A 24-hour notice is required for cancellation of an appointment, or you will be charged in full for the appointment. Payment is due before your next appointment.

Tardiness Appointment times are as scheduled and cannot extend beyond the stated time to accommodate late arrivals. Please be on time for your appointment.

Sickness Massage/bodywork is not appropriate care for infectious or contagious illness. Please cancel your appointment as soon as you are aware of an infectious or contagious condition. If it is within the 24-hour notice period, the cancellation fee may be waived.

Cancellation

Amid the ongoing uncertainty of COVID-19, we have modified our cancellation policy to offer greater flexibility to all our clients. We hope this will alleviate any stress and hesitation you have about an upcoming appointment. If you need to reschedule for whatever reason, and especially if you are not feeling well, we understand and request you to please contact us as soon as possible to reschedule. To further support you, there will be no penalties for cancellations at this time.

Assignment of Benefits

Your signature below authorizes and directs payment of medical benefits to the massage/bodywork practitioner for services provided by this office.

Client Intake Form

Gender
Is this massage/bodywork medically necessary (is it for a medical condition, injury, surgery)?
Do you have a physician referral/prescription?
Are you seeking insurance reimbursement?
Massage Information Have you ever received professional massage/bodywork before?
Do these symptoms interfere with your activities of daily living (e.g., sleep, exercise, work, childcare)?
Are you wearing contacts?
Are you wearing dentures?
Are you wearing a hairpiece?
Are you pregnant?
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