Health Intake & Informed Consent
Insurance Claim Form
Assignment of Benefits
Copy of Informed Consent Form
It is my choice to receive bodywork, coaching/facilitation or energy work. I realize that the treatment is being given for the well-being of my body and mind. I understand it is my responsibility to communicate with my practitioner at any time I feel like my well-being is being compromised and I agree to let the practitioner know if I am uncomfortable or the pressure, technique, or style is not to my liking or if I am uncomfortable for any other reason. I also understand and acknowledge that Swedish/Full Body/Relaxation Massage is not offered at Body Integrity.
I have stated all medical conditions that I am aware of and will update the massage practitioner of any changes in my health status.
I understand that bodywork is not a substitute for medical examination or diagnosis, that it is recommended that I see and concurrently work with a primary health care provider for any condition I may have. Massage therapists do not diagnose illness, disease, or any physical or mental disorder, nor do they prescribe medical treatment or pharmaceuticals.
I understand that all sessions are strictly therapeutic and not of a sexual nature and that any illicit or sexually suggestive remarks, advances, or innuendo will result in the immediate termination of the session and I will be liable for services rendered. The amount of the full session will be charged in the case of early termination.
Contact Information & Confidentiality:
I understand my information is held private and confidential and is released only with my permission or as required by law. My contact information will only be used for contacting me and will never be sold or shared. My information will only be used to notify me of appointment information and policy changes, one-on-one correspondence, corresponding with my primary health care provider, and for insurance billing purposes.
No Show/Cancellation Policy:
All no shows or sessions canceled with less than 24 hours notice will be billed a small fee. Fee must be paid in full before booking your next session. Multiple no shows may require a deposit to secure a reservation. The fee amount will be refunded or deducted off your service at the time of payment. Personal insurance and insurance claims do not cover missed appointments, therefore you will be billed directly. In the case of a late arrival, the session will end at its scheduled time. Email cancellations are not accepted, and may incur a fee.
No Show/Late Cancel Fee: $25/60-minute session, $30/75-minute session, $35/90-minute session, $45/120min session.
Payments & Billing:
Our standard rates are $30 per unit (15 minutes). Sessions may be billed or paid at the time of service. We offer a Prompt Pay Incentive (PPI) for sessions paid at time of service ($20/unit). Several pre-paid packages are also available at an additional discount.
All sales are final. Though non-refundable, all sales are fully transferable between sessions and classes at the paid price (not promotional price).