Client Intake Form

Please fill out the bold only, if a non medical injury massage.

Date

Patient Last: First: Initial: Sex: Male Female

Address:

City: State: Zip:

Date of Birth: Phone #: Cell Phone #:

Social Security #: Driver’s License #:

E-Mail: Occupation:

Employer:

Employer’s Address:

Insurance Carrier: Policy #:

ID #: Group #: Claim #: Accident Date:

Adjuster’s Name:

Adjuster’s Address:

City: State: Zip:

Telephone #: Extension:

Time and Date of Insurance Verification:

Primary Health Care Provider:

Provider’s Address:

City: State: Zip:

Telephone #: Extension:

Permission to Consult with Primary Provider? No Yes (Please initial if yes)

In Case of Emergency, Please Notify:

Name: Telephone #:
Relationship:

Confidential Health Information

Please answer the following questions by checking the box and providing any necessary
clarifications.

Yes No Arthritis
Yes No Autoimmune Disorder
Yes No Bleeding/Grinding Teeth
Yes No Cancer
Yes No Contact Lenses
Yes No Diabetes
Yes No Diverticulitis/Diverticulosis
Yes No Phlebitis
Yes No Fatigue/Depression
Yes No Headache
Yes No High Blood Pressure
Yes No Infectious Conditions
Yes No Loss of Balance
Yes No Painful Joints
Yes No Pins/Needles
Yes No Previous Car Accidents/Trauma
Yes No Ruptured/Bulging Disc
Yes No Scoliosis
Yes No Seizures
Yes No Skin Disorders
Yes No Stroke
Yes No Varicose Veins
Yes No Are you pregnant? Which term?
Yes No Are you currently under the care of a Physician, Chiropractic, or Naturopathic?
Yes No Deep Vein Thrombosis( Blood clots)

Anything that was answered Yes to, please explain further.

 Massage History
Yes No Have you received a professional massage before?

Please list the areas that you do not want to be massaged, reference diagram also.

Using symbols below, mark on body diagram:

X = Pain B = Burning T = DO NOT TOUCH L = Other

N = Numbness C = Cramping Z = Tingling S = Shooting

Using the line scale, indicate the severity of the pain you are experiencing now by circling a
number with 0 being no pain and 10 needing to be at the hospital.

0 1 2 3 4 5 6 7 8 9 10
Please circle correct answer.

How often do you have this pain? Consistant Hourly Daily Weekly Monthly

Does this interfere with your: Work Sleep Daily Routine Recreation

Activies or movements that are painful to perform: Sitting Standing Walking Bending Lying down
 Timothy J Cosden NA MA LMP

418 Carpenter Rd Se, Ste 104

Lacey WA 98503 LIC MA 60071009

Myoskeletal/Massage Therapy Informed

Consent
I, , (client or minor) understand that massage therapy
provided by, Timothy Cosden, (Myosketel therapist) is intended to reduce pain caused by
muscle tension, increase range of motion, and improve circulation.

Any specialized therapy listed below has been discussed in detail, a video showing the detail of
how the Myoskeletal massage is done, draping of the client and who will be in the room.
Example: pelvic floor massage.

The general benefits of massage, possible massage contraindications and the treatment
procedure have been explained to me. I understand thatMyoskeletal massage therapy is not a
substitute for medical treatment or medications, and that it is recommended that I concurrently
work with my Primary Caregiver for any condition I may have. I am aware that the massage
therapist does not diagnose illness or disease, does not prescribe medications, and that spinal
manipulations are not part of massage therapy.

I have informed the massage therapist of all my known physical conditions, medical conditions
and medications, and I will keep the massage therapist updated on any changes. I understand
that there shall be no liability on the practitioner’s part due to my forgetting to relay any
pertinent information.

If I experience any pain or discomfort during the session, I immediately communicate that to
the therapist so the treatment can be adjusted.

I have received a copy of the therapist’s policies, I understand them and agree to abide by them.

Client or Guardian of Minor Signature Date

 Timothy J Cosden NA MA LMP

418 Carpenter Rd Se, Ste 104

Lacey WA 98503 LIC MA 60071009

SIGNATURE ON FILE
● I authorize use of this form on all my insurance submissions.
● I authorize release of information to all my insurance companies.
● I authorize the insurance companies to make payments to my
therapist directly.
● I permit a copy of this authorization to be used in place of the
original.
● I authorize my release of documentation to my attorneys, and any
representative on their behalf.
● I understand that I am responsible for my bill.
● I understand that if I do not cancel my appointment 24 hours
before the scheduled appointment time, I will be charged for
that appointment.

● I understand that after 4th no show to an appointment I will no

longer be a client of Cosden Massage Clinic.

Print Name:

Signature of Patient or Guardian:

Date:
 Timothy J Cosden NA MA LMP

418 Carpenter Rd Se, Ste 104

Lacey WA 98503 LIC MA 60071009

Please read if you are paying with insurance.

If you are using insurance from Labor and Industry or a personal injury
claim, we will not charge the $50 office visit. All other insurance
patients will be asked to pay for the office visit at the time of service.
Due to the reluctance of insurance companies to pay, or to pay the
entire bill, a service charge is now in place. For 13 years our company
has never charged our clients for the difference between what
insurance companies are billed and what is actually paid to us.
With the current economic conditions, we can no longer absorb the
losses. The upside of this new policy is that no matter what the
insurance company pays, even if it pays zero or rejects the claim
altogether, the client will only be paying the $50 office visit.
I have fully read the statement and agree to pay the $50 charge each
time I receive service.

Client’s signature__________________________