Informed Consent

Sharon Mitchell,GA L.M.T, NCBTMB

What to Expect

The first session begins with an interview that includes health history, condition assessment, informed consent, and release of medical information. Each session will address your specific massage therapy needs. Privacy and confidentiality are maintained at all times.
Clothing may remain on during the massage. However, maximum benefits will be attained if all clothing is removed. The body will be covered with sheets for privacy and warmth. Only the body area being massaged will be uncovered. Breasts and genitals are never exposed or massaged.
All oils and lotions are hypoallergenic.
The sequence of the massage will vary based upon the plan of care.
A full body massage includes the face, scalp, neck, chest, arms, hands, abdomen, back, hips, legs, and feet. There will be low lighting and relaxing music in the treatment area to facilitate relaxation.
During the session, client should immediately inform me if anything makes them uncomfortable.
You may be sore for up to two days if the massage is focused on injury treatment or is deep in nature. Please inform me if soreness lasts more than two days.
I will not treat any client under the influence of alcohol or drugs.
Parent/legal guardian must remain with minor clients for the entire session.
Massage therapy is for therapeutic benefit and will be administered in a professional and ethical manner

Financial Agreement

In the unfortunate event that you must cancel/reschedule your appointment, we require a 24 hour notice. We will charge 50% of the scheduled service fee for no shows and same day appointment cancellations. We therefore require a credit card or gift certificate number to hold your requested appointment time.
Your card will not be charged at the time of making the appointment, but only for a no show or same day cancellation. We appreciate your understanding in this matter due to the fact that missed and no show appointments are very costly to the massage establishment and results in lost income to the staff.
Understand that if you, the client, write a check and it is returned to Healing Touch or Sharon Mitchell marked insufficient funds that you will be charged a $40.00 returned check fee, in addition to the amount of the check. This also stands for a credit card payment that is denied after services have been rendered. In the event that fees are not paid as requested, a collection agency and possible legal action may follow. If so, you, the client, will be responsible for all costs associated with the collection of your debt.

Assignment of Benefits

I, the client, am responsible for all charges for services provided. In the unfortunate event that my insurance company denies payment, or only makes a partial payment, I am responsible for any balance due.I authorize and direct payment of medical benefits to Healing Touch/ Sharon Mitchell, for services billed.

Release of Medical Records

I authorize the release of medical records and other healthcare information, including reports, chart notes, intake forms, correspondence, billing statements, and other written information to my healthcare provider(s), insurance case manger(s), and attorney(s), to Healing Touch/Sharon Mitchell. (Please inform your Physician as soon as possible upon signing any exclusive Release of Medical Records with your attorney that may impact the above.)

By providing my email address on my intake form, I agree to receive email correspondence from Sharon Mitchell GA L.M.T., NCBTMB, and Healing Touch.

Other

Other than the aboved mentioned who may we speak to about your treatment:

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Informed Consent

I have been informed about the proposed treatment, including the sequence, possible techniques, areas of emphasis, duration of treatment, and associated fees. Furthermore, I certify that I have provided the therapist with any and all medical information that may have bearing on the effects of this treatment. I agree with the professional guidelines outlined during this intake session, and understand that both I and/or the therapist have the right to terminate the treatment at any time and for any reason. It is my responsibility to communicate any discomfort throughout the treatment. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session; and I will be liable for payment of the scheduled appointment in full. I hereby certify that I am requesting the proposed treatment. I also give my permission for Sharon Mitchell to discuss my massage therapy with my health care provider.

I hereby understand and agree to all the terms listed above.

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Client signature today's date

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Signature of Parent/Legal Guardian today's date