|
Back In Balance
Last Name: ___________________ First Name: ___________________ Date: ____________
Date of Birth: ____________ Age: ____________ Weight: _________ Height _____________
Address: ______________________________________________________________________
Phone: ________________________________ Cell: __________________________________
E mail address: ________________________________
Emergency Contact: ________________________________ Phone: ____________________
Primary Care Physician: ____________________________ Phone: _____________________
Current Health Conditions: Please mark all that apply and provide an explanation.
Heart Condition:  Currently Pregnant (What trimester) ________
High Blood Pressure Arthritis Unusual Swelling
Diabetes Nerve Damage Chest Pains
Difficulty Breathing Recent Surgeries Past Surgeries
Cancer Irregular Heart Beat Other Chronic Illness
Explain: _______________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Current Medications: Name, Purpose, Dose.
______________________________________________________________________________
______________________________________________________________________________
Have you ever received massage therapy before? Yes No Frequency? _________
Do you receive other alternative care? _____________________________________________
Reason For Initial Visit? ________________________________________________________
Do you smoke? Yes No (If so, how much) ____________________
Drink Alcohol? Yes No (If so, how much) ____________________
Do you consume caffeine? Yes No __________________________________
Sugar/ Artificial Sweeteners Yes No ___________________________________
Do you exercise? Yes No (If so, how often?) _____________________________
Any allergies, sensitivities to the following: Oils/ Lotions: Scents:
Do you wear Dentures: Yes No Hearing Aid: Yes No
Contact Lenses: Yes No
How did you hear of Nitasha Canine, Back In Balance? ________________________________
Nitasha Canine and Back In Balance adhere to the following standards and codes of ethics: The American Massage Therapy Code of Ethics and Standards of Practice. I adhere to the National Academy of Sports Medicine’s standard of practice and code of ethics. I adhere to IDEA health and fitness standards of practice and code of ethics. The National Guild of Hypnotists, The State Board of Chiropractic Examiners, and The National Certification Board for Massage and Bodywork. I am governed and regulated by these organizations.
I am dedicated to giving you the highest quality service available by meeting all standards of practice, licensing and continuing education for all of the services I provide.
I do not accept health insurance; therefore do not accept co pays or agree to reimbursements. A receipt can be given if you wish to submit it to your insurance company.
Gift certificates are available. Payment is due at the time of purchase and must be used by the expiry date.
All clients are protected under a 100% confidentiality policy.
Payments can be made with Checks, Cash or credit card by PayPal.
Because of the exclusive and tailored nature of this small business, all clients are asked to give a credit card in which to hold booked appointments. Back In Balance requires a 24 hour notice for cancellation or to reschedule. Appointments made on the same day require a 2 hour cancellation or rescheduling notice. The credit card will not be billed unless the client fails to give the required notice. If the required notice is not given, the full fee for the session booked will be charged to the client’s credit card. Clients who must cancel due to injury or illness will be excused from the fee, with a medical slip.
Sexual advances, solicitation and or harassment will not be tolerated by Back In Balance. Any client who engages in this type of behavior will be asked to leave and will be billed for his session. Choosing service with Back In Balance is an acknowledgment of this policy.
Last Name: ___________________ First Name: ___________________ Date: ____________
Date Of Birth: __________ Phone: _____________________________
Contract Continued:
“In consideration for my being permitted to use these services, I waive and release forever any rights for claims and damages I may have against Nitasha Canine or Back In Balance, in any manner due to any personal injuries or property loss sustained by me in connection with the use of these services. I attest that I am physically able to receive the treatments made available to me and that I am 18 years of age or older.
SIGNATURE: ____________________________________________ DATE: ____________
I authorize Back In Balance to effect payment for services at the published rate to the credit card listed below should I either cancel my appointment or attempt to reschedule my appointment without 24 hours notice, or not show up for my scheduled appointment. I agree to pay Back In Balance a $25.00 service fee as a result of not having sufficient funds or credit available in my account. If I discover any unauthorized payments, alterations, or other errors in my account, I must notify Back In Balance within 30 days of when I receive my statement. I agree that if I fail to report any forgeries, alterations, signatures or any other errors to my account within 30 days, I cannot assert a claim against Nitasha Canine and or Back In Balance concerning any items in my statement.”
AUTHORIZING SIGNATURE: ___________________________________ DATE: ____________
Credit Card: VISA, MASTERCARD, DISCOVER, AMEX
Credit Card Number: __________________________________________________
Expiration Date: ______________ V- Code: _______
Name on Card: ___________________________________________________
AVAILABLE MONDAY TO FRIDAY 10 AM - 7 PM. LAST APPT. TAKEN AT 6 PM.
CONTACT NITASHA FOR YOUR APPOINTMENT
OFFICE: 443.223.4676 HOME OFFICE: 443.292.4205
E-MAIL NITASHA FOR YOUR APPOINTMENT
appointment@backinbalance.info
MASSAGES
2508 Airy Hill Circle Crofton MD 21114 (By appointment)
1203 West Street Suite E Annapolis, MD 21401
|
