• Avise Chiropractic Massage Intake

  • Personal Information

  •  - -
    Pick a Date
  •  - -
    Pick a Date

  • Health History

  •  - -
    Pick a Date

  • Please check any of the following that you now have or have had

  • Office Policy

    I have completed this form to the best of my knowledge and will inform the massage therapist of any changes to my physical health. I understand that a massage therapist cannot diagnose illness, disease, or any other medical, physical or emotional disorder, nor perform any spinal adjustment. I am responsible for consulting a Physician or Chiropractor for any physical ailments that I have. I understand that massage therapy is a therapeutic health aide and is non-sexual. I understand that if the massage therapist starts a session late, the time will be made up at the end of the massage hour if possible, or reduce my fee accordingly. I understand that if I arrive late, my session will end at the originally scheduled time so that the person following me is not penalized.

  • Financial Policy

  • I agree to give a 24- hour notice for a schedule session that I cannot keep. I am aware that I will be charged $35 for any missed sessions or for sessions that I do not give 24-hour notice to cancel or reschedule.      

    All copayments, deductibles, and no insurance covered charges must be paid at time of service.      

    We will prepare and send all claims to your insurance on your behalf      

    Insurance benefits quoted are not a guarantee of payment by my insurance company. I understand that I am responsible for all charges incurred with my provider       

    I have read and understand the Terms of Acceptance, Financial Policies and agree to the above terms. I also understand that the practice may amend the terms from time to time.

  • Clear
  •  - -
    Pick a Date

  • Treatment of a Minor

  • I      parent of      have read and fully understand the terms above and hereby grant my permission for my child to receive massage therapy at Avise Chiropractic.

  • Clear
  •  - -
    Pick a Date
  • Should be Empty: