Save time by completing your intake form right here! We'll print it out for you and have you sign it right in our office on the day of your appointment. Its safe, secure, and convenient.

Health History
Are you currently under the care of a health provider?

Yes No
If yes, please explain:
List stress reduction activities, exercise and frequency:
List any prescription or OTC drugs you are taking:
List surgeries and date:
List accidents and date:
Please rate your stress level:

1 2 3 4 5

Low High
Are you allergic to any oils or lotions? *

Yes No

Acknowledgement of Treatment

Please take a moment to read and initial the following statements:
I affirm that I have notified the therapist of all medical conditions and injuries. In addition, I agree to inform my health care provider and the therapist of any changes in my health and medical condition. I understand that there shall be no liability on the therapist's part should I forget to do so.

I also understand massage thereapy is not a substitute for medical care. The massage therapist does not diagnose illnesses or diseases, nor perform any spinal manipulations and does not prescribe any medications/treatments. I will immediately inform the therapist if I experience any pain or discomfort and the therapist will adjust the pressure/strokes to my comfort level. I will not hold the therapist responsible for any pain or discomfort I experience during or after the session.

Finally, I understand the unclothed body will be draped at all times for warmth, sense of security, and as a mark of professionalism. Massage therapy is not sexual in any manner and any illicit or suggestive remarks/behavior on my part will result in immediate termination of the session. Payment is expected in full; regardless if the session is completed or not.
By initialing here, I affirm that I have read and agree to the statements above regarding my Massage Therapy Treatment. *
Suggestions
- Remove jewelry when undressing.

- Contact lenses will dry out during your session. Remove and wear glasses or plan to use lubricating eye drops.

- Pull long hair back with a hair band or clip.

- Massage therapy is given while you are unclothed. You may choose to wear undergarments. You will be draped with a sheet throughout the entire session. This is your massage and you should feel as comfortable as possible.

Financial Responsibility
PLEASE NOTE:
Dr. Laura Nunno does not participate with insurance companies. If you have out-of-network benefits, you can submit to your insurance for reimbursement.

I understand that all payments are due at the time of service and I agree to be financially responsible for any and all charges incurred. Should collection efforts be necessary, a 15% interest charge will be added to the balance due. I am liable for any cost incurred by Holistic Health Center in collection efforts.
Check below to indicate you have read the terms regarding your financial responsibility. *

I have read and agree to these terms.
Appointment Policy

Please respect the time of our Doctor, Massage Therapists, and those on the waiting list by

giving at least 24 hours notice when cancelling.

The full session fee will be charged for no-shows and last minute cancellations.

Privacy Policy
Federal law requires Holistic Health Center of Cromwell to notify patients regarding our Privacy Practices and policies. A copy of our Policies is prominently displayed in our waiting room, available for all patients to reference and keep at any given time. Any revisions made to our Policies will be updated accordingly. A copy of our Policies may be made available upon request.

Federal Law requires Holistic Health Center of Cromwell to retain any and all signatures, forms and patient information obtained and documented for a minimum of seven (7) years.
Please check below to indicate you have read our Privacy Policy: *

I have read the Privacy Policy.

Signature and Submission
We will print this document and have it ready for you to sign on the day of your appointment. Please click 'Submit.'
Signature (in-office):

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Date:

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Therapist Signature (in-office use):

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Massage Therapy Intake

History

Health History

Heath History Continued

Acknowledgement of Treatment

Suggestions

Financial Responsibility

Privacy Policy

Signature and Submission