(Please Print)
Last Name: ______
First Name: ______Middle Name: ______
Date of Birth: ______
Physical Address:______City: ______
State: ______Zip: ______Employer: ______
Mailing Address (if different): ______
Home Phone: _ _ _ /_ _ _ /_ _ _ _ Cell Phone: _ _ _ / _ _ _ / _ _ _ _ Work Phone: _ _ _ / _ _ _ / _ _ _ _
E-mail Address: ______
I authorize J & S Center For Wellness to use the following:
Physical Address ¨ Mailing Address ¨ E-Mail Address ¨
Home Phone ¨ Work Phone ¨ Cell Phone (For Texting Purposes) ¨
to contact me with appointment reminders, newsletters, new products and services, monthly promotions, birthday and holiday related greetings and information about alternative treatments to meet my individual needs.
Appointment Reminder Preference: (Please Circle One) Email / Text / Both
J & S Center for Wellness will not transfer, copy, share or sell my information to a second party for any reason.
Signature:______Date: ______
Emergency Contact: ______
Relationship: Phone: _ _ _ / _ _ _ / _ _ _ _
How did you hear about J&S Center for Wellness: ______
Medical History
If you are under the care of a Physician, please provide name: ______
Explain: ______
Have you experienced alternative therapy before: Yes / No
If yes, what type of therapy: ______
Primary reason for seeking massage:
Please mark:
(X) conditions that apply now (P) past conditions (F) family history
34952 S. Ellis Rd. Molalla, OR 97038 (503) 829-5918www.jscenterforwellness.com
___headaches/migraines
___vision problems/contact lenses
___hearing problems/deafness
___injuries to face or head
___sinus problems
___dental bridges/braces
___jaw pain/TMJ problems
___asthma or lung conditions
___infectious disease
___high/low blood pressure
___birth control
___abdominal or digestive problems
___chronic pain
___muscle or joint pain
___muscle, bone injuries
___numbness or tingling
___sprains, strains
___arthritis, tendonitis
___cancer, tumors
___spinal column ___disorders
___constipation, diarrhea
___pregnancy
___heart, circulatory ___problems
___broken bones
___fatigue
___tension, stress
___depression
___sleep problem
___allergies
___skin irritations
___athletes foot
___blood clots
___varicose veins
___hernia
___smoke
___lymph nodes removed
34952 S. Ellis Rd. Molalla, OR 97038 (503) 829-5918www.jscenterforwellness.com
34952 S. Ellis Rd. Molalla, OR 97038 (503) 829-5918www.jscenterforwellness.com
Explain any areas noted above:______
______
Please list any other medical conditions not listed:______
______
Please list all allergies:______
Current medications (including aspirin, ibuprofen, herbs, vitamins, homeopathy, etc.:______
______
Please list all forms and frequency of stress-reduction activities, hobbies, exercise, or sport participation:______
Please take a moment to carefully read the following information and sign.
If you have a specific medical condition or specific symptoms, massage may be contraindicated. A referral from your primary care provider may be required prior to the session. I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain, discomfort or numbness during the session, I will immediately inform the practitioner so that the pressure can be modified to my comfort level. I further understand that massage should not be constructed as a substitute for medical treatment or diagnosis, and that nothing said in the course of the session should be constructed as such. I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agreeto keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioners part should I forget to do so.
Client Signature:______Date:______
Facility Policy
J & S Center for Wellness is committed to creating a safe environment for everyone to enjoy. The policies below are designed to execute that directive.
Smoking Policy:
J & S Center for Wellness is a non-smoking facility. Smoking is prohibited anywhere on the property.
Children Policy:
J & S Center for Wellness welcomes children. We want them to enjoy their time at our facility, but we need them to be safe and quiet while waiting for their parent/guardian. We do not have a childproof office or surrounding facility. We have retail items that are not toys, please do not allow children to play with them unless you wish to purchase the item (s).
We do not have the staff to provide childcare. We ask that if you must bring your children that they stay either in the treatment room with parent/guarding or sit quietly in the waiting room or on the office patio area. (See policy of outdoor environment.)
Outdoor Environment:
No playing in the yards, on or around the water feature, play structure, or barn yard areas. If staff is available private tours of our outdoor farm facility may be arranged in advance.
Please be respectful of other clients/patients and our personal property. We reserve the right to inform you and your children if behavior is dangerous or inappropriate and to bodily remove children from danger if urgently necessary.
Print Name:
Signature: Date:
34952 S. Ellis Rd. Molalla, OR 97038 (503) 829-5918www.jscenterforwellness.com
34952 S. Ellis Rd. Molalla, OR 97038 (503) 829-5918www.jscenterforwellness.com
Financial and Appointment Policy Agreement
Accepted forms of payment are cash, checks, Visa, MasterCard, American Express, and Discover
We can bill all automobile insurance companies for you convenience, but there is no guarantee the insurance company will pay. Any balance remaining after your insurance has processed claims will be billed to you. Claims not processed within 120 days will also be billed to you. If late claims are eventually paid, any overpayments will be promptly refunded.
We bill for all medically necessary services including manual therapy. Some insurance plans may process these services under your physical therapy or other benefits and/or pass some charges on to you for non-covered services. You may decline these modalities at any time. We are happy to answer any questions you may have.
If you have a deductible, payment for treatment will be required at the time of service until your deductible has been met for the year.
You are ultimately financially responsible for any balances due to our office.
A 1.5% interest charge will be added to overdue balances monthly.
Appointments: Out of respect for our time and ease in scheduling of others, we request that you please call the office at least 24 hours in advance if you are unable to make your scheduled appointment.
A 50% fee of the normal rate is directly charged to you for missed appointments "No Show" or those canceled without a 24 hours notice. This includes auto insurance and cash clients/patients.
Rates: Our appointment rates vary depending upon time and complexity. Our current appointment fee schedule is available upon request. A discount is offered for payment in full at the time of service.
"No-Show," Late Cancel Fees: J&S Center for Wellness will retain credit/debit card information on a secure client record and will only use this information in the event of a "no show" or an appointment cancelation with less than 24 hour notice.
Print Name
Signature Date
New Patient Consent to the Use and Disclosure of Health Information for Treatment, Payment, or Healthcare Operations
Use and Disclosure of Health Information Patient Initial Here:
I understand that as part of my health care, J & S Center for Wellness originates and maintains paper and/or electronic records describing my health history, symptoms, examination, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as:
· A basis for planning my care and treatment.
· A means of communication among the many health professionals who contribute to my care.
· A means by which a third-party payer can verify that services billed were actually provided.
· A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals.
I understand that J & S Center for Wellness is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that J & S Center for Wellness has already take action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, J & S Center for Wellness may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations.
I further understand that J & S Center for Wellness reserves the right to change their notice and practices and prior to implementation, in accordance with Section 164.520 of the Code of Federal Regulations. Should J & S Center for Wellness change their notice, they will send a copy of any revised notice to the address I've provided (whether US mail or, if I agree, email).
I wish to have the following restrictions to the use or disclosure of my health information:
I understand that as part of J & S Center for Wellness' treatment, payment or health care operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosures via email, US mail, and/or fax.
Patient Signature Date:
Acknowledgement of Receipt of Notice of Privacy Practices
Notice of Privacy Practices Patient Initial Here:
I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:
· The right to review the notice prior to signing this consent.
· The right to object to the use of my health information for directory purposes.
· The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operations.
Patient Signature Date:
34952 S. Ellis Rd. Molalla, OR 97038 (503) 829-5918www.jscenterforwellness.com