Massage Intake Form

Emergency Contact:

Health History:

Do you smoke?

Please list and explain. Include dates and treatment received if possible:

Family Medical History

Siblings:

Please check All Current and Previous Conditions:

General:

Skin Conditions:

Endocrine System:

Respiratory and Cardiovascular:

Reproductive System:

Muscles and Joints:

Digestive/ Elimination System:

Nervous System:

Cancer or Tumor

Contract for Care:

I promise to participate fully as a member of my health care team. I will make sound choices regarding my treatment plan based on the information provided by my manual therapist and other  members of my health care team, and my experiences of those suggestions. I agree to participate in the self-care program we select. I promise to inform my practitioner any time I feel my well being is threatened or compromised.

I expect my manual therapist or other health care  professional to provide safe and effective treatment. Consent for Care It is my choice to receive care, and I give my consent to receive treatment. I have reported all health conditions that I am aware of and will inform my practitioner of any changes in my health.

Massage Therapy Health Report

CP – Constant pain
P – Pain
S – Swelling
T – Tenderness
N – Numbness
Tg – Tingling
R – Redness
E – Effusion (puffiness or edema)
L - Limitation
W - Weakness

Identify the Intensity of your symptoms: Select the number on the scale to show the amount of pain or symptoms you’re experiencing today.

Functional Rating Index

Please select the closest number for pain/ discomfort/ limitation for your current primary complaint.

Consent for purposes of Treatment, Payment and Health Care Operations

I consent to the use or disclosure of my protected health information by Bourree Chiropractic and Massage for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations of Bourree Chiropractic and Massage.

I understand that diagnosis or treatment of me by the Massage Therapist may be conditioned upon my consent as evidenced by my signature on this document.

I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment, or health care operations of the practice. Bourree Chiropractic and Massage is not required to agree to the restrictions that I may request. However, if Bourree Chiropractic and Massage agrees to a restriction that I request, the restriction is binding on Bourree Chiropractic and Massage and Dr. David Bourree. 

I have the right to revoke this consent in writing at any time except to the extent that Dr. David Bourree or Bourree Chiropractic and Massage has taken action in reliance on this consent.

My “Protected health information” means health information including my demographic information, collected from me and created or received by my physician, another health care provided, a health plan, my employer or a health care clearinghouse. This protected health information relates to my past, present, or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me.

I understand I have a right to review Bourree Chiropractic and Massage’s Notice or Privacy Practices prior to signing this document.

Bourree Chiropractic and Massage’s Notice of Privacy has been provided to me. 

The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills, or in the performance of health care operations of Bourree Chiropractic and Massage.

This Notice of Privacy Practices for Dr. David Bourree is also provided at the front desk of Bourree Chiropractic and Massage.

The Notice of Privacy Practices also describes my right and the duties of Dr. David Bourree and  staff with respect to my protected health information.

Bourree Chiropractic and Massage reserves the right to change the privacy practices that are described in the Notice of Privacy Practices.

I may obtain a revised notice of privacy practices by calling the office and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment.

Massage Therapy Missed Appointment Policy

All appointments are scheduled time with you and your Massage Therapist; when an appointment is missed, someone else could have had that scheduled time with the therapist.

Twenty-Four Hours’ advanced notice is required for an appointment cancellation.

If advanced notice is not given, a missed appointment fee of $110.00 will be charged directly to you. Insurance companies do not pay for missed appointments, and it must be paid before your next visit to this office.

Please keep your appointments.
I have read and agree to the above.

Insurance Non-covered Service

Disclosure and Agreement

Type of Service:

Massage Therapy – 97124 $45.00 for 1 Unit,   97140 $50.00 for 1 Unit

Proposed dates or range of dates of service: See massage therapy care schedule. Potential Reasons for Non-covered Status:

• The service is or may not be deemed investigational or experimental under the carrier’s internal guidelines.
• The service is considered, or may deemed, not medically necessary under the carrier’s internal care or cost management guidelines. *Maintenance care is not covered by insurance.

• The service is not or may not be actually covered under the plan to which the patient is subscribed.
• The service is not or may be deemed as not provided in accordance with the Provider’s Agreement with the carrier or other requirements of the carrier’s or managed care entity’s internal guidelines.

The carrier authorizes the provider to charge the patient for the above services so long as this disclosure is made and signed by the patient prior to the services being provided.

Patient Financial Responsibility:

The undersigned patient acknowledges that the Non-Covered status of the proposed service(s) has been explained, and that a certain portion of the patient’s care may not be covered by or has not been authorized by the patient’s insurance plan.

The undersigned acknowledges that if any portion of the care provided is not, or may not be, covered by insurance, then the undersigned shall be responsible for payment, and shall make the necessary financial arrangements with the healthcare provider to pay for these services.

Phone: 425-827-0334

Fax: 425-284-6884