Consent Forms

Massage for the Entire Family. In-Home Healthcare and Group Classes.

Available Courses

Medical Information 

Practitioner/Clinic Name: _____Cynthia "Cindy" Scott LMT/TX # 122542/BCTMB__________

Contact Information: [email protected] / MTCINDY-143 (682)463-9143

Client Contact Information

Client Name: ___________________________________ Date: ____________

Date of Birth: ____________ Gender: ____________

Address: _________________________________________________________________________________

Phone: _______________________________________ Email: ___________________________________

Referred by: ___________________________________

Emergency contact: _____________________________ Phone: ___________________________________

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 ☐ If yes, please complete the Billing Information form.

Type of insurance coverage for this claim: Car Collision Worker’s Compensation Private Health

Massage Information

Have you ever received professional massage/bodywork before? Yes ☐ No ☐

How recently? ___________________________________

What types of massage/bodywork do you prefer? ___________________________________

What kind of pressure do you prefer? Light Medium Firm

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 ☐

Health History

Have you had any injuries or surgeries in the past that may influence today’s treatment?

______________________________________________________________________________________________

Circle any of the following health conditions that you currently have (If you are unsure, please ask):

blood clots, infections, congestive heart failure, contagious diseases, pitted edema

Please answer honestly, as massage may not be indicated for the above conditions.

Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received:

Current Past Muscle or joint pain _____________________________________

Current Past Muscle or joint stiffness _____________________________________

Current Past Numbness or tingling _____________________________________

Current Past Swelling _____________________________________

Current Past Bruise easily _____________________________________

Current Past Sensitive to touch/pressure _____________________________________

Current Past High/Low blood pressure _____________________________________

Current Past Stroke, heart attack _____________________________________

Current Past Varicose veins _____________________________________

Current Past Shortness of breath, asthma _____________________________________

Current Past Cancer _____________________________________

Current Past Neurological (e.g. MS, Parkinson’s, chronic pain) _____________________________________

Current Past Epilepsy, seizures _____________________________________

Current Past Headaches, Migraines _____________________________________

Current Past Dizziness, ringing in the ears _____________________________________

Current Past Digestive conditions (e.g. Crohn’s, IBS) _____________________________________

Current Past Gas, bloating, constipation _____________________________________

Current Past Kidney disease, infection _____________________________________

Current Past Arthritis (rheumatoid, osteoarthritis) _____________________________________

Current Past Osteoporosis, degenerative spine/disk _____________________________________

Current Past Scoliosis _____________________________________

Current Past Broken bones _____________________________________

Current Past Allergies _____________________________________

Current Past Diabetes _____________________________________

Current Past Endocrine/thyroid conditions _____________________________________

Current Past Depression, anxiety _____________________________________

Current Past Memory Loss, confusion, easily overwhelmed _____________________________________

Comments:

______________________________________________________________________________________________

______________________________________________________________________________________________

Consent for Treatment

If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my

level of comfort. I further understand that massage/bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and

that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that

massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and

that nothing said in the course of the session given should be construed as such. Because massage/bodywork should not be performed under certain

medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated

as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that

any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the

scheduled appointment. Understanding all of this, I give my consent to receive care.

Client Signature: _____________________________________________________________ Date: ____________

Parent or Guardian Signature (in case of a minor): ___________________________________ Date: ____________