Forms

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

First Name

Last Name

By checking the boxes, you confirm that you agree with the following statements:

I Agree to obey the rules of the studio during the appointment to minimize the spread of viruses.

I confirm that I have not been diagnosed with COVID-19 in the last 14 days.

I verify that I am not waiting for laboratory test result for COVID-19.

Do you have any of these symptoms: cough, shortness of breath, high fever, muscle pain, body ache, nausea, loss of taste/smell?

Yes

No

Within the past 14 days, have you been in contact with anyone that has COVID-19 symptoms or has gotten infected?

Yes

No

Are you living with anyone that is infected or quarantined due to COVID-19?

Yes

No

Thanks for submitting!

Office Policies

Client Information

Client Name:

Date:

Date of Birth:

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.

Signature

Date:

Thanks for submitting!

Client Intake Form

Client Full Name:

Date of Birth:

Date:

Gender

Female

Male

Other

Address

Phone:

Email:

Emergency Contact Name:

Emergency Contact Phone Number:

Referred by:

Physician/Health-care Provider Name:

Phone:

Is this massage/bodywork medically necessary (is it for a medical condition, injury, surgery)?

Yes

No

Do you have a physician referral/prescription?

Yes

No

Are you seeking insurance reimbursement?

Yes

No

Massage Information Have you ever received professional massage/bodywork before?

Yes

No

How recently?

What are your goals/expected outcomes for receiving massage/bodywork?

How do you feel today?

List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):

Do these symptoms interfere with your activities of daily living (e.g., sleep, exercise, work, childcare)?

Yes

No

Explain:

List the medications you currently take:

Are you wearing contacts?

Yes

No

Are you wearing dentures?

Yes

No

Are you wearing a hairpiece?

Yes

No

Are you pregnant?

Yes

No

Thanks for submitting!

Please fill out & submit forms prior to your first appointment

Consent Form During Covid-19 for
Myofascial Release of Berkeley

Client Name

Office Policies

Client Information

Cancellation

Assignment of Benefits

Client Intake Form

Please follow us on social media & feel free to leave us a review!

FORMS

Please fill out & submit forms prior to your first appointment

Consent Form During Covid-19 for Myofascial Release of Berkeley

Client Name

Office Policies

Client Information

Cancellation

Assignment of Benefits

Client Intake Form

Consent Form During Covid-19 for
Myofascial Release of Berkeley