New Client Intake Form

Intake Form


Contact Information


In Case Of Emergency


Medical Information


Current Symptoms


Describe The Pain


Pain Is


Pain Intensity: (0 no pain 5 average, 10 extreme)

 


Describe Your Condition


1. Injury events - include car accidents, breaks, sprains, etc. (check all that apply and explain)


2. What are the physical demands of:


Indicate on a scale of 1 to 10 your level of stress over the last two years.
(1 being the lowest and 10 being extreme)

Indicate the source of your stress: (check all boxes that apply and explain)


Medical History


Medical (Men)


Medical (Women)


Dental History


Family Health History (parents and siblings)


Sleeping Habits


Nutrition, Diet, Exercise, Supplements, and Medications


Type Of Diet


Food Sensitivities / Allergies


Eating Frequency


Exercise


Supplements And Medications


Health Habits

Past = before this year

Current = this year


Tobacco


Alcohol


Caffeine


Water


Other


Food Frequency


What Is Your Goal In Seeking Treatment at Michael Westgate Therapy?


Westgate Therapy

150 Nellen Avenue, Suite 200

Corte Madera, CA 94925

415-924-2323


Welcome to Westgate. Please read the following and sign below to indicate your agreement to our policies and procedures.

 

Disclosure, Consent to Treatment and Assumption of Risk

I understand that I am going to receive treatment from Westgate and hereby consent to this treatment. I understand that the services will be provided by Michael Westgate, a Certified Massage Practitioner, licensed by the State of California. As a Certified Massage Practitioner he has successfully completed, at an approved school, curricula in massage and related subjects, including anatomy and physiology, contraindications, health and hygiene, and business and ethics, and has passed all background and safety checks.

 

I have been duly informed of the nature, risks, and possible complications or consequences of Westgate's therapeutic massage treatments. I agree to inform the therapist about any special needs which I have concerning my health, and to discuss my goals in receiving this treatment. I will inform the therapist about all of my existing medical conditions or illnesses and will inform him if anything does not feel good or helpful for those purposes for which I have chosen to receive sessions. I agree to keep the therapist updated as to any changes in my medical condition and understand that there will be no liability on the practitioner’s part should I forget to do so.

 

I understand that massage therapy is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the technique may be adjusted. I further understand that massage therapy should not be construed as a substitute for a medical examination, diagnosis, or treatment and that I should consult a physician, chiropractor, or other qualified medical practitioner about any mental or physical ailment that I am aware of. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, or to diagnose or treat any physical or mental illness, and that nothing said in the course of this therapy should be construed as such.

 

I understand that I am responsible for monitoring my personal state during and after all my appointments with Westgate and will report any unusual consequences I might experience to Westgate. I will make sure any questions I have are answered to my satisfaction.

 

I am undergoing this treatment voluntarily of my own free will, and I understand that I may stop or limit this treatment at any time without explanation. I have neither asked for nor received any guarantees or promises as to the results which will be obtained.

 

I understand that my right to privacy and confidentiality will be respected by Westgate. The privacy policy and practices of Westgate have been explained to me, and I have received written notice of them, as required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

 

I understand that there may be risks arising out of my voluntary participation in receiving therapeutic massage treatments. As consideration for being permitted to receive such treatments I accept and assume complete responsibility for all such risks and, to the maximum extent permitted by public policy and the law, I hereby voluntarily waive any and all claims I may have, now or in the future, against Michael Westgate, Westgate, or any of its practitioners, employees, agents, or representatives (hereafter referred to as “the Released Parties”), for any and all personal injury, emotional injury, sickness, disease, death, property damage, economic damage or any other loss arising out of or in connection with my receipt of therapeutic massage treatments, or my presence in or about Westgate's office, even if the injury, damage or loss was caused by or aggravated by the negligence, carelessness or other act or failure to act of any of the Released Parties.

 

I HAVE CAREFULLY READ THIS DISCLOSURE, CONSENT TO TREATMENT AND ASSUMPTION OF RISK, AND I FULLY UNDERSTAND AND AGREE TO EACH OF ITS TERMS. I SIGN THIS AGREEMENT KNOWINGLY AND VOLUNTARILY.

 

I hereby acknowledge that I have received a copy of this Agreement and Westgate's Privacy Policy


Sign Here

If the client is a minor, the parent or guardian must sign this statement:

I hereby give my consent as parent or guardian for the following individual to receive treatment and related services from the designated professional(s) providing services at Westgate. I understand that this consent is for the duration of the services to be provided. I have read, understood, and agree with the limits of confidentiality. I hereby give my consent as parent or guardian for the following individual to receive treatment. This is also to acknowledge that I have read and agree with the Westgate Notice of Privacy Practices.

Sign Here

 

Information and Suggestions for Clients

  • Prior to your Trigger Point Therapy session, please remove contact lenses and all jewelry.

 

  • As a rule, Trigger Point Therapy is given while you are clothed. We suggest you wear a "Yoga" or "Gym" outfit, or T-shirt and shorts. This is your session and you should feel as comfortable as possible.

 

  • During your session, you may want to give your therapist feedback as to pressure (deeper or lighter) or point out painful or ticklish areas of your body.

 

  • Feel free to ask your therapist any questions about the procedure. Your therapist is a highly trained professional committed to keeping you well informed and comfortable.

 

  • Please, refrain from smoking prior to your session. Do not use perfume or hairspray before your session. Also, please keep in mind that a face down position can smear makeup.

 

  • Payment: We accept cash, personal checks, Visa and MasterCard for our services and any product purchases. Payment is due at the time services or products are received. All products purchased have a 100% money back guarantee within 30 days of purchase. After 30 days of purchase no returns are accepted. A $25.00 fee will be applied for any returned checks or dishonored credit card payments.

 

  • Side Effects: Side effects of massage therapy, which are known to occur in some individuals, have included light bruising, light-headedness, drowsiness, and aches. It is advisable to walk for 15 minutes after your treatments, drink 8-10 glasses of water daily, and take a hot bath or sauna to reduce the chance of side effects and to increase the effectiveness of the session.

 

  • Cancellation Policy: We have a 48 hour cancellation policy. W need to know 48 hours ahead of time if you wish to cancel or reschedule your appointment. Without 48 hours prior notice payment will be due in full.

 

  • Westgate reserves the right to refuse to provide treatment to anyone.

 

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