Elevated Health Center Muscle Work

*** To be completed AFTER a referral from Dr. Oommen ***

PERSONAL INFORMATION

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HEALTH INFORMATION

Have you had massage/bodywork before? *
Do you have any difficulty lying on your front, back, or side? *
 
Do you have any allergies to oils, lotions, or ointments? *
 
Do you sit for long hours at a workstation, computer, or driving? *
 
Do you perform any repetitive movement in your work, sports, or hobby? *
 
Do you experience stress in your work, family, or other aspect of your life? *
 
If you answered YES to the question above, how do you think it has affected your health? *
 
Are there any major injuries and/or surgeries we should know about? *
 
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Have you seen any other providers for this condition? *
 
Is there a particular area of the body where you are experiencing tension, stiffness, pain or other discomfort? *
 

HEALTH CONCERNS

Select any concerns that apply to you: *
Vitamins/Supplements *
Check any medications being used: *

STRESS QUESTIONNAIRE

Physical Stress *
 
Chemical Stress: *
 
Emotional Stress *
 

PATIENT HIPAA CONSENT FORM

Protecting the privacy of your personal health information is important to us. Disclosure of your protected health information without authorization is strictly limited to define situations that include emergency care, quality assurance activities, public health, research, and law enforcement activities. Any other disclosures for the purposes of treatment, payment, or practice operations will be made only after obtaining your consent. You may request restrictions on your disclosures. You may inspect and receive copies of your records within 30 days with a request. You may request to view charges to your records. In the future, we may contact you for appointment reminders, announcements, and to inform you about our practice and its staff. I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: conduct, plan, and direct my treatment and follow up with multiple healthcare providers who may be involved in that treatment directly or indirectly, obtain payment from third party payers, and conduct normal healthcare operations such as quality assessments and physician's certificates. I have read and understand your Notice of Privacy Practices. I also understand that I can request in writing that you restrict how my personal information is used and disclosed. *
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AUTHORIZATION FOR CARE

At Elevated Health Center, we do not diagnose or treat any disease or condition other than vertebral subluxation and the doctors/clinic will not be held responsible for any pre-existing medical conditions. I certify that the above information is correct to the best of my knowledge. I will not hold the doctors or any staff member of Elevated Health Center responsible for any errors or omissions that I may have made in the completion of this form. While the care offered is remarkably safe, you need to be informed about the potential risks related to your care to allow you to be fully informed before consenting to treatment. Please inquire if you have further questions. Muscle work/bodywork is a system of health care delivery and therefore, as with any health care delivery system, we cannot promise a cure for any symptom, condition, or disease as a result of treatment in this office. An attempt to provide you with the very best care is our goal, and if the results are not acceptable, we will refer you to another provider who we feel can further assist you. I hereby authorize the doctors and staff at Elevated Health Center to treat my condition as deemed appropriate. *
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CANCELLATION POLICY

Here at EHC, we have a strict 24-hour notice cancellation policy. You may cancel your appointment anytime 24 hours or more before the appointment without a charge. Unless it is an emergency, if a client does not show up OR call to cancel a scheduled appointment, the client will be charged $50.00 for the scheduled visit. Any cancellations or rearrangements within 24 hours preceding said appointment will be charged at $25.00 for the scheduled visit. We understand sometimes life can throw us unexpected emergencies and these unanticipated things are not always within our control. Thank you for your understanding and we look forward to helping you elevate your health! I have read the above statement and agree to the above terms. *
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