Massage Doctor	MASSAGE DOCTOR PLLC Dr. Abdul Karim Taifour, LMPC Phone 206-226-2527, Fax 866-305-5149 P.O. Box 27612, Seattle WA 98165 www.massagedoctor.com	INTAKE INFORMATION PACKET

Name	How did you hear about us?
first middle initial last
Address
street address apt #	city state zip code
E-mail	Date of birth	/ /
month day year
Phone	Cell/other	Text message?	ok no
Emergency contact	Phone(s)
Marital status: single married other Employment status: employed full-time student part-time student

Massage and Medical History

Have you received professional massage before?	No Yes – date of last session / frequency
What results do you want from your massage sessions?
Prioritize the areas of your body that you would prefer to be massaged:
What do you do for stress reduction and exercise, and frequency?
List current medications, including aspirin, ibuprofen, etc.
Surgeries/Accidents (and dates)

AREAS OF HEALTH PROBLEMS: (if yes, please provide detail)

No Yes	Musculo-skeletal
No Yes	Nervous system
No Yes	Digestive
No Yes	Circulatory
No Yes	Pregnant – if yes, estimated due date:	Any complications?
No Yes	Infectious disease
No Yes	Skin
No Yes	Medications – if yes, list current (including aspirin, ibuprofen, etc.)
No Yes	Other – anything else we should be aware of:

Informed Consent for Treatment

Your Choice for Healthy Treatment. It is your choice to receive massage therapy treatment for the well-being of your body and mind; this may be for stress reduction, for increasing circulation or energy flow, or relief from muscular tension, spasm or pain. Though massage therapy is generally safe, it could have potential complications in certain cases or conditions; it is therefore important that you keep your therapist fully informed of your medical history and medications, and also discuss with your primary care physician about receiving massage. Some massage therapy treatments have some slight risks, with very low incidence – e.g., aggravation of pre-existing symptoms, allergic reaction from lotions or oils, pain, fainting, or bruising. By signing below, you are agreeing to communicate with your therapist immediately about anything during our work together that does not enhance your well-being.

Questions. Your therapist will answer any questions you have as fully as possible. Results of the therapy being performed on me are not guaranteed. Your practitioner cannot anticipate all risks and/or complications, although all appropriate precautions will be taken to provide the best treatment possible based on training and Washington State laws and regulations. By signing below, you agree to communicate any time you feel your well-being is compromised or if you feel any discomfort or pain, and you confirm that you are receiving services with informed consent.

Scope of Practice. You are agreeing to work as a client with a state licensed massage practitioner. Massage therapists do not diagnose illness, disease, or any physical or mental disorder; nor prescribe medical treatment or pharmaceuticals; nor perform spinal thrust manipulations. Massage therapy is not a substitute for medical examination or diagnosis. A recommendation from a heath care provider may be necessary in order to receive massage therapy. Massage therapists can refuse to provide services that may be unsafe. Massage therapy is a professional, clinical health service – any actions that may be construed as sexual advances or unsafe behavior will be reported to the appropriate authorities.

Providers. Your provider is a Licensed Massage Practitioner (LMP), licensed by the State of Washington and Nationally Certified by the NCBTMB, with over 1500 hours in Massage and Bodywork Education and 50+ hours in Continuing Education every year. Techniques and modalities used may include: Swedish Massage, Deep Tissue Therapy, Hydrotherapy (use of water, heat, hot or cold stones or compresses), Aromatherapy, Lymphatic Drainage, Acupressure, Trigger Point Therapy, Myofascial Release Technique, Neuromuscular Technique, Peripheral Joint Mobilization, Reflexology, Thai Yoga Massage, Shiatsu, Guided Meditation, Breathwork, Energy/Chakra Balancing Methods, Stretching, Remedial Exercise.

Each independent practitioner has his/her own state licensing, malpractice insurance and business licensing. We are always open for suggestions and open to hearing issues that may arise between you and your therapist. Every effort will be made to provide you with the highest quality service. By signing below, you agree to not hold your practitioner or any business owner personally liable for legal or financial issues or situations that arise with your practitioner.

Practice Policies

HIPAA-Compliant Operations. Your privacy is important to us. Your personal information will be protected in compliance with federal law under the Health Insurance Portability and Accountability Act of 1996. If your personal file needs to be reviewed by anyone outside (for instance, an insurer), you will need to sign a release form. Our full privacy policy is available on our website at http://www.massagedoctor.com/HIPAApolicy.pdf

Practice Communication. By agreeing to receive services, you are opting in to receive education and announcements about the practice via mail or email. Your personal information is never shared (nor sold) to third parties, in compliance with HIPAA.

RULE of 24. In effort to provide all of our clients with outstanding service, 24 hours notice is required for all cancellation notices and rescheduling requests. Please respect our time and our other clients’ requests by providing us with 24 HOURS NOTICE:

* If you do not show for a scheduled appointment without canceling, you will be charged the full fee of the scheduled service.

* If you cancel with less than 24 hours notice, you will be charged half the fee of the scheduled service.

* If you are more than 15 minutes late for a scheduled appointment, you may be required to reschedule and the rescheduling fee may apply. We reserve the right to treat each situation on a case-by-case basis.

Financials. Payments are due at your session or within 30 days of receipt of the invoice. Returned checks will be subject to the maximum fee allowed by law. Unpaid balances over two months past due will incur a late payment fee of $10 per month. Detailed statements for third-party reimbursement (for example, a flexible spending account) are available upon request. By signing below, you are acknowledging your financial liability for your requested services.

My signature below confirms that:

I have been informed about and am consenting for massage therapy treatment,

I have stated all the medical conditions that I am aware of and will share any change in my health status,

I am aware of clinic policies, including cancellation and no-show fees, outlined above,

I accept full financial responsibility for all services provided, including fees outlined above, and

This consent form is valid for today and all subsequent sessions, unless revoked in writing by me.

Client signature	Date signed	/ /
Print full name	Date of birth	/ /
If completing electronically, enter name in signature line and initial:	month day year

Insurance Information

Patient Responsibility: YOU are responsible for verifying your benefits for massage therapy with your insurer.

Be sure to clarify eligibility, coverage, requirements for referrals or prescriptions, and any limitations prior to your first session.

You are responsible for all charges incurred from treatment received prior to coverage verification.

Your insurance company requires that you pay the copayment, coinsurance, or deductible as noted by your insurer on the EOB (explanation of benefits) that you and your provider both receive from your insurer. We cannot waive these, that’s insurance fraud.

If you have Medicare, you must have a secondary insurance, as Medicare does not cover massage. We reserve the right to not re-bill secondary carriers.

Policies. Every effort will be made to collect billable charges from your insurance company. However, we reserve the right to wait no more than 90 days following any billing procedure; should payment be delayed or refused, you will be invoiced directly and responsible for paying all charges within 30 days of receipt of the invoice.

Insurance ID number	Policy Group or FECA number
Insurance Plan Name	Employer or School Name

Are you the primary insured on the policy? Yes - if not, please provide the following for the primary insured:

Name	Date of birth	/ /
first middle initial last	month day year
Address
street address apt #	city state zip code

Is there another / secondary health benefit plan? No - if yes, please provide the following for the insured:

Name	Date of birth	/ /
first middle initial last	month day year
Insurance ID number	Policy group / FECA number
Insurance plan name	Employer or school name

Are you receiving treatment today due to an accident or injury? No - if yes, please provide the following:

Date of injury	/ /	Where	Unable to work?	/ / to / /
month day year	State	Specific dates from/to
Employment related: L&I claim number	Employer
Auto accident: insurance company	Primary policyholder
Claim number	Policy number
Representative/adjuster	Phone	Fax
Address for sending claims
street address or PO Box	city state zip code
Third-party / personal injury: Insurance / payor	Claim number
Contact/attorney	Phone	Fax
Address for sending claims
street address or PO Box	city state zip code

My signature below confirms that:

I am giving permission to communicate with my insurer or other payor and any referring physician,

I accept full financial responsibility for all services provided, including fees outlined above, and.

This consent form is valid for today and all subsequent sessions, unless revoked in writing by me.

Client signature	Date signed	/ /
For electronic signature, type name above and initials here:	month day year