Health Information

Abstract

Client Contact Information Client Name: ___________________________________ Date: ____________ Date of Birth: ____________ Gender: ____________ Address: _________________________________________________________________________________ Phone: _______________________________________ Email: ___________________________________ Referred by: ___________________________________ Emergency contact: _____________________________ Phone: ___________________________________ Physician/Health-care Provider name: __________________________ Phone: ____________________ Is this massage/bodywork medically necessary (is it for a medical condition, injury, surgery)? Yes ☐ No ☐ Do you have a physician referral/prescription? Yes ☐ No ☐ Are you seeking insurance reimbursement? Yes ☐ No ☐ If yes, please complete the Billing Information form. Type of insurance coverage for this claim: Car Collision Worker’s Compensation Private Health