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Patient Demographic


Emergency Contact

Massage Therapy Consent Form

By signing below, you agree to the following:

  • I voluntarily request and consent to receiving massage therapy.

  • I understand that the massage service offered is for the purpose of general wellness, stress reduction, and relief of muscular tension only.

  • I do not have any injuries or conditions that prevent me from receiving massage therapy. I understand the importance of informing my massage therapist of all medical conditions and medications that I am taking, and that there may be additional risks based on my physical condition.

  • If I experience any pain or discomfort, I will immediately inform my therapist so that the pressure or techniques used can be adjusted to my comfort level. I will not hold my massage therapist responsible for any pain or discomfort I experience during or after the session.

  • I understand the risks associated with massage therapy include, but are not limited to:

    • Superficial bruising

    • Short-term muscle soreness

    • Exacerbation of undiscovered injury

  • I have not received a positive test for coronavirus within the past 14 days, and currently have no symptoms.

  • I do not have any contagious conditions that may put my massage therapist or other clients at risk.

  • I understand that I or the massage therapist may terminate the session at any time.

  • I have been given the opportunity to ask questions about massage therapy and my questions have been answered.


I have been advised of the policies and procedures pertaining to massage and I understand these policies. Information regarding massage in general, benefits, contraindications of massage, and possible alternative therapies have been explained to me. I further understand that massage therapy is not a substitute for a medical examination or treatment, and that I should see a physician or other qualified health specialist for any mental or physical ailment of which I am aware. I understand that massage therapists do not diagnose illness or disease, and nothing said during the massage should be construed as such. My consent is informed and voluntary and I understand that I may withdraw my consent at any time except for actions already taken.

Our Responsibilities

We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

By signing this form, you acknowledge you were advised of the HIPAA Notice of Privacy Practices. Our HIPAA Notice of Privacy Practices provides information about how we may use and disclose your protected information. We encourage you to read it in full. Our Notice of Privacy Practices is subject to change. You may request a copy of the Notice of Privacy.

Financial Policy

Thank you for choosing Holistic Elite as your health care provider. Please carefully read and Initial each statement and sign below. This policy has been put in place to ensure that financial payments due are recovered to allow us to continue to provide quality medical care for our patients. It is important that we work together to assure that payment for services is as simple and straightforward as possible. Our practice manager or billing department will be glad to discuss these policies with you. Please initial below:

1. I understand that if I am unable to make a scheduled appointment, I need to contact Holistic Elite at least 24 hours before my scheduled appointment time. Due to a demand for appointments, missed appointments prevent us from scheduling appropriately and keep others in need from being seen. A $35 FEE WILL BE ASSESSED FOR ALL MISSED APPOINTMENTS NOT CANCELED WITH AT LEAST 24 HOURS ADVANCED NOTICE.

2. I understand that if my accounts not paid in full within 90 days of a statement date, a 35 collection agency processing fee will be added to the outstanding balance and will be turned over to collections for further processing. No additional appointments will be made for delinquent accounts until they are brought current.

I have read and agree to all the provisions of the above financial policy. I understand that I am ultimately responsible for all professional fees incurred for professional services performed by the attending physician.

Form Submitted!

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