NEW CLIENTS - FIRST VISIT INTAKE FORM
MY PRACTICE DOES REQUIRE AN INITIAL " INTAKE INTERVIEW"
BEFORE SCHEDULING YOUR FIRST APPOINTMENT IT IS NECESSARY TO COMPLETE AN INTAKE FORM
To help me with your first evaluation I have THREE DIFFERENT intake forms. Please click the appropriate form for your
condition to download a copy. Print a copy, fill it in and bring it to your first session.
INTAKE FORMS: MYO PAIN CENTER OC offers a variety of services; therefore I have two types of initial intake interviews developed. They are different in duration and the initial evaluation and physical assessment as part of your first appointment.
The “STANDARD INTAKE INTERVIEW” (75 min) is designed for a regular client seeking relaxation, nourishment, or stress reduction treatment. Massage Therapy would be the modality to meet those needs. Symptoms are mild and usually tightness or stiffness.
The “COMPREHENSIVE INTAKE INTERVIEW” (90 min) is used with acute and chronic pain patients, Worker’s Compensation patients, and individuals with injuries who primarily seek treatment for pain relief. Myofascial therapy is best suited for this problem. For those individuals, a medical history sheet and a different evaluation need to be completed and the best approach to treatment has to be determined. Symptoms are dull ache, sharp pain, soreness, tingling, numbness, cold fingers or feeds, etc.
The “LYMPHATIC INTAKE INTERVIEW” (75 min) The lymphatic system (aka the sewer system) is an important component of your immune system and plays a vital role in the body by regulating the immune system, which protects your body against infection. It transports nutrients to cells and eliminates metabolic wastes, toxins, and excess fluids from your body.
1. STANDARD INTAKE FORM
Select this intake if you are coming for bodywork with “NO Medical Conditions”
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2. MEDICAL INTAKE FORM
Select this intake if you have
“An Acute or Chronic Condition”
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3. LYMPHATIC INTAKE FORM
Select this intake if you have
“An Acute or Chronic Condition”
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CLIENT POLICY
Thank you for taking the time to read this short but important statement. The purpose of this statement is to determine what is and what is not acceptable and to establish professional boundaries, I welcome questions and will try to accommodate your needs regarding the procedures laid out in these three pages. I am looking forward to meeting you.
My goal is to provide the highest quality care (Massage Therapy and Myofascial Therapy) to those who seek professional service. I perform only those services for which I am qualified. My practice does require an initial “intake interview” and the completion of an intake form. More details you will find on pages two and page three.
FEE- PAYMENT - CANCELLATIONS - REFUNDS
BUSINESS DAYS & HOURS
Monday to Friday - 8:00 am to 5 pm.
“Saturday appointments and out-calls are available by special request. All treatments or sessions are by appointment only.” Please call me at 949-413-1567
CONFIDENTIALITY
Confidentiality is used to protect client and patient information. If it becomes necessary to share information about one’s care with other professionals involved in their care or insurance companies paying the bill, my practice is required to attain permission to release medical information. Information about care and treatments are shared only if the client or patient signs a statement authorizing it.
IMPORTANT INFORMATION
Pregnant women and individuals with high blood pressure, heart conditions, or under medical care should consult a physician before scheduling a session.
Thank you for taking the time to read this statement. If you have any questions please feel free to ask. I am looking forward to working with you.
Carlos Messerschmidt.
(LMT, CMTPT, NCTMB)
