New Patient Intake & Policy Form - Ross Therapeutic Massage

Step 1 of 3 - Information

Name(Required)

First Last

Email(Required)

Phone(Required)

On a scale of 1-5, how would you rate your pain level?(Required)

Please describe your pain(Required)

What are the main concerns we need to address during your session?(Required)

How does this effect your daily life and how long have you been dealing with this pain?(Required)

Have you experienced this problem before?(Required)

Cancellation/Rescheduling

Hello and Welcome! I am very excited that you are here and taking steps towards achieving your health goals! Please note that your session will only be booked once you read and agree to the statements below. We are 100% committed to your satisfaction and comfort! Please read, and agree to each statement below to ensure you have a great experience!

If I am unable to make my scheduled appointment for any reason, I agree to cancel or reschedule the appointment at least 24 hours in advance. I agree to pay 50% of the full session if I give less than 24hours notice.(Required)

I Agree

I agree to pay the full session rate if I give less than 2 days’ notice, or if I miss an appointment without giving notice.(Required)

I Agree

I understand that I am responsible for my appointment time until I hear back confirming that an email or phone call was received to cancel my appointment.(Required)

I Agree

I understand that I must arrive 10 -15min prior to my appointment time in order to get my full session time in and review any paperwork prior to my session and will pay full session rate if arrive past scheduled appointment time.(Required)

I Agree

I understand that in order to receive the best treatment possible I know that I have to communicate anything and everything to my therapist. Including my needs preferences, requests or feedback. If at any time before, during, or after the session I will communicate right away anything that is distracting me, I feel unwell or uncomfortable at any time during the session so that adjustments can be made. I understand that my therapist wants honest feedback positive or negative to make your session the best ever!(Required)

I Agree

Comments

This field is for validation purposes and should be left unchanged.