Whole Body Balance Massage Form

Whole Body Balance

Please fill out this form as completely and accurately as possible.
Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Cell Phone*
Home Phone
Email*
example@example.com
Date of Birth*

MonthDayYear
Emergency Contact Name*
Emergency Contact Phone*
How did you hear about Whole Body Balance?*

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By signing below, I agree that I have read and understand the following:
- I certify that the above information is true and accurate to the best of my knowledge.

- I understand that massage is not a replacement for medical care and that no diagnosis will be made. I understand that the massage and bodywork that I receive is provided for the purpose of relaxation, stress reduction and the relief of muscular tension. If I experience any pain or discomfort during the session I will immediately inform my massage therapist.

- I understand that any illicit or sexually suggestive remarks or advances made by me will result in termination of the session and I remain responsible for payment o fthe entire scheduled appointment

Consent for Treatment
- Our time together is precious and I understand that if I meed to reschedule an appointment for any reason, I will give at last 24 hours notice or be responsible for the full time of service fee. If necessary, in the future, I may be required to prepay with my credit card number to secure my appointment.

Privacy Policy

- We will use your e-mail / phone number for appointment reminder, our promotions and news only. Your privacy is important to us. We will not sell, rent or give an of your personal information to anyone.
HIPAA Information & Consent
The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. This form is a "friendly" version. A more complex text is available upon requests.
What this is all about:
Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as a patient. We balance these needs with our goal of providing yo with quality professional service and care. Additional information is available from the U.S. department of Health and Human Services. www.hhs.gov
We have adopted the following policies
1. Patient information will be kept confidential except as is necessary to provider services or to ensure that all administrative matters realated to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care/ Patient files may be stored in open file ranks and will not contain any coding which identifies a patients condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for handing of chards, patient records, PHI and other documents or information.
2. It is the policy of this office to remind patients of their appointments. We do this by e-mail or text. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative.
3. You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties.
4. You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or healthcare provider.
5. Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services.
6. We agree to provide patients with access to their records in accordance with state and federal laws.
7. We may change, add, delete or modify any of these provisions to better serve the needs of the practice and the patient.
8. You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within this office concerning your PHI. However, we re not obligated to alter internal policies to conform to your request.
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