Hidi_MHlogo

Meridian Health Seattle

Acupuncture, Massage Therapy & Chinese Herbal Medicine

Seattle Mhc Skyline32.jpg

MHC Intake Form

Thank you for wanting to fill out the Intake Form online.

BEFORE FILLING IN THE FORM BELOW, PLEASE READ…

Acupuncture / Massage Therapy Policies

1. Please fill out paperwork prior to your first acupuncture or massage therapy treatment, or arrive 10 minutes early so that it does not cut into your time.

2. It is expected that you disrobe for your treatment. The only exposure will be the area that is being worked on. This is for comfort and efficiency throughout your treatment.

3. Please arrive for your treatment clean and showered.

4. Please do not wear any perfume for your treatment. Deodorant is okay.

5. The one hour scheduled treatment includes time for paperwork, interviewing and changing sheets.

Thank You!

Please make sure you answer as best you can. Those fields marked with an * are required. If a field is required and you don’t have information to fill in just type in none or n/a.

    Patient Information

    Type of Phone number:

    Your Age:

    Sex*:

    Emergency Notification Information

    Current Medical Information

    Have you been treated with Massage or Acupuncture Before?*

    Main problem(s) that you want help with:*

    How long ago did this problem begin?*

    Have you been given a diagnosis for this problem? If so, what?

    List any stress reduction and exercise activities. Include frequency.

    List current medications, including herbal remedies, aspirin, etc.*

    Past Medical History

    Please enter your past medical history here include dates. Required

    Significant Illnesses: Please check all that apply.

    Have you had any Surgeries?

    Significant Trauma (auto accidents, fall, etc.):

    Allergies (drugs, chemicals, foods):

    Please mark any of the following that you now have, or have had in the past(indicate side of body where necessary):

    MUSCULOSKELETAL

    NERVOUS SYSTEM

    DIGESTIVE

    CIRCULATORY

    RESPIRATORY

    SKIN

    REPRODUCTIVE

    [text his-reproductive-other placeholder ""List Other/include stage of pregnancy if it applies"]

    OTHER

    CHECK ALL THAT APPLY TODAY


    Additional Client Remarks/Comments:

    Financial Disclosure

    Thank you for choosing me as your health care provider. I am committed to successfully treating you. The following is a statement of my financial policy that I require you to read, agree to and sign prior to receiving treatment. All patients must also complete the Confidential Client Intake Form prior to receiving treatment.
    Full payment is due at the time of service, unless other arrangements have been made and stated herein.
    Cash and checks are acceptable methods of payment.

    If you have made ALTERNATIVE FINANCIAL ARRANGEMENTS, please list below:

    If you have insurance coverage, payment will be insurance co-pays and moneys to be applied towards the deductible. Your co-payment and/or deductible will be estimated based on the benefit quote from your insurance company. Ultimately, it is your responsibility to check with your insurance company to see if your plan covers acupuncture/massage therapy, and what your yearly benefit is. Concerns about coverage for services are between you and your insurance carrier. I am not an employee of any insurance carrier. If your yearly insurance benefit for acupuncture/massage therapy has been fulfilled, you will be responsible for all fees incurred for my services, until your benefit period renews.

    Final payments will be based on the explanation of benefits form that I receive from your insurance company. Any difference between your original payment and the actual patient responsibility listed on the form will be either refunded, or due at that time.

    You must give 24 hours notice if you cancel your appointment for these sessions. If you fail to give 24 hours notice, you will be billed a penalty of $25.

    A legal guardian must accompany a minor (patient under 18) in order for the minor to receive non-emergency treatment. Alternative arrangements must be made, in advance of the appointment, if this is not possible.

    Acupuncture/massage therapy is an integral part of your rehabilitation program and/or wellness program.

    Any feedback or suggestions about my services are always welcomed and encouraged. Thank you in advance for your understanding and compliance with these policies.

    Because a massage therapist/acupuncturist must be aware of any existing physical conditions that I have, I have listed all my known medical conditions and physical limitations and will inform the massage therapist/acupuncturist in writing of any change in my physical health. I understand that a massage therapist/acupuncturist neither diagnoses illness, disease, or any other medical, physical, or emotional disorder, nor performs any spinal manipulations. I am responsible for consulting a qualified physician for any physical ailment that I have.

      ACCEPTANCE. I have read, understand, and agree to the above policies regarding services for acupuncture/massage therapy and the associated co-payments and/or deductible payments. I have also provided to the best of my knowledge information regarding my medical information.

    Client Signature: (Patient or Responsible Party) Sign below

    Date: July 24, 2024 2:52 am