Intake Form - Copper Moon Massage

PLEASE NOTE: I AM ONLY ACCEPTING NEW CLIENTS WHO HAVE BEEN IN AN AUTO ACCIDENT and are USING PIP insurance or have a 3rd party claim with attorney representation. If this does not apply to your situation, please click here.

Understand conditions *

I understand that Copper Moon Massage Therapy is currently only accepting clients who meet the above conditions.

Basic Information

Name *

Date of birth *

Date of INJURY *

Phone (H) *

Phone (M)

Email *

Address *

Address Line 1

City

State

Zip Code

Emergency contact *

Relationship *

Phone *

Insurance Information

Employer *

Employer phone *

Health Insurance Carrier *

Phone *

Patient ID *

Group ID *

Auto / P.I.P. insurance carrier *

Adjuster phone *

Email *

3rd party (responsible party's insurance) *

Adjuster phone *

Medical Information

Primary physician *

Who wrote your massage Rx? *

Please list any medications you are using. *

Are you currently pregnant? *

Yes
No

Do you have any risk factors? *

Yes
No

Please list any procedures or surgeries you have had *

Please list any allergies or sensitivities or skin conditions *

Notes / additional information

By signing below, you agree to the following:

I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes. I understand that the massage therapy that I am given is for the purpose of stress reduction, relief from muscular tension or spasm and or improving circulation and range of motion. I understand that a massage therapist neither diagnoses illness, disease, or any other medical, physical or mental disorders, nor performs any spinal manipulations. I am responsible for consulting a qualified physician for any physical aliment I may have. In addition, I understand and agree that I am financially responsible for all charges for services rendered. I acknowledge that I am personally financially responsible for any balance on my account after my insurance and/or settlement has been paid. A copy of the HIPPA agreement has been made available to me.

Terms agree *

I have read and agree to the above terms

Kari Jones, LMT

Client Intake Form

Basic Information

Insurance Information

Medical Information

By signing below, you agree to the following:

Contact Info

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