Charleston Center For Therapeutic Massage Intake Form

Name (First and Last) *

Address (Street, City, State) *

Email Address *

Phone Number *

How did you hear about us? *
FriendFamily MemberPhysician ReferralWeb PageMUSC Wellness CenterSocial MediaChair Massage FunctionAre you affiliated with any of the following groups? *Wellness Center MemberMUSC EmployeeMUSC StudentNOAA EmployeeNone of the aboveOther

Emergency Contact (Name and Phone Number)

Are you under the care of a physician? If so, who?

Date of Birth

Have you had treatment with us before? *
YesNo

Present areas of discomfort *
NeckShoulderWrist/HandBackHipsKneesFootAnkleOther

Do you exercise regularly? *
YesNo

If so, what type and frequency?

Are you taking any medications? *
YesNo

If so, what type and for what conditions

Past Medical History ( please check all that apply) *
ArthritisCardiac Risk FactorsLow Back PainHerniated/Bulging DiscsBurning, Tingling, or Numbness in Arms or LegsBroken BonesBalance ProblemsFibromyalgiaJoint ReplacementGI IssuesHigh Blood PressureTendinitis/ TendonosisCancerTMJDSpinal IssuesOsteoporosisPlantar FasciitisSciaticaScoliosisCarpal TunnelThoracic Outlet SyndromeWhiplashFrozen ShoulderLow Blood PressurePregnantDiabetesOther

Have you had any surgeries? Please include type of surgery and date it was performed. *

If you have been pregnant, how many times and what type of delivery did you have? (Vaginal or Cesarean)

If you have had any surgery, did you complete your rehabilitation? Please explain.

1. CONSENT: I voluntarily authorize and give consent to the C4TM to provide its services to me. I understand that the services provided by C4TM are not a substitute for medical examinations or diagnosis, and it is recommended that a physician may be consulted for that service.

2. AUTHORIZATION: I authorize the release of any information contained in my C4TM record for the following purposes: "to assist in processing claims, if applicable to provide information to my health care practitioners: chiropractor/PT/physician."

3. CANCELLATION POLICY: I understand that C4TM requires a minimum of 24 hours notice for any cancelled appointment. This is necessary to meet the needs of all of our clients and to provide the best possible service. I understand that a fee of $60 will be charged to me for the first cancellation that occurs with less the

4. SAFTEY AND RESPECT: We provide a professional and safe environment. We treat our clients with the utmost courtesy and respect and expect the same treatment, in return. Anything outside of this is not acceptable and your C4TM therapist reserves the right to end the session or not re-book a follow-up session if this boundary has been crossed. Our right to safety and respect is non-negotiable.

I Have Read and Agree to These Terms and Conditions