Renaissance Chiropractic Center

253-473-0300

Massage Intake

If you plan to visit us solely for a massage appointment or if you require a referral from your doctor, we kindly ask that your healthcare provider email the referral to [email protected] before your initial appointment. Please be aware that your referral must be on record with our office prior to scheduling.

**Appointments cancelled with less than 24-hour notice will be charged a $40 missed fee.


Renaissance Chiropractic Center

4902 Tacoma Mall Blvd., Tacoma, WA 98409 253-473-0300

Massage Intake Form

May we contact you at work?
Marital Status*
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Is this appointment related to*
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Do we have your:

General & Medical Information:

If you answer "yes" to any of the following questions, please explain as clearly as possible.

Have you ever had a professional massage?*
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Do you experience frequent headaches?*
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Are you pregnant? If yes, how far along?*
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Are you wearing contact lenses?*
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Do you have high or low blood pressure?*
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If yes to the previous question, are you taking medication for this?
Are you diabetic?*
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Do you have any skin problems or allergies? If yes, to what?*
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Have you had any recent surgeries? If yes, please explain*
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Have you had any broken bones in the past two years?*
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Do you have tension or soreness in a specific area?*
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Do you have cardiac or circulatory problems?*
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Do you have varicose veins?*
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Do you have numbness or stabbing pains anywhere?
Are you very sensitive to touch / pressure in any area?*
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Do you have an infectious or contagious disease?*
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Do you suffer from seizure disorder or epilepsy?*
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Do you have any other medical conditions that I should be aware of?*
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Mark problem areas with an

PLEASE TAKE A MOMENT TO CAREFULLY READ THE FOLLOWING INFORMATION AND SIGN WHERE INDICATED.

(If you have a specific medical condition or specific symptoms, massage / bodywork may be contraindicated. A referral from your primary care provider may be required prior to service being provided.) I understand that the massage / bodywork I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I immediately inform the therapist so that the pressure and / or strokes may be adjusted to my level of comfort. I further understand that massage / bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should consult a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage / bodywork therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage / bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. 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 therapists part should I neglect to do so. It is also understood 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.

Financial Policy:

We ask that patient pay at the time of each visit, unless other specific arrangements are made.

Cancellation Policy

The time of your appointment is reserved for you. Please give 24 – 48 hours notice if you are unable to keep your appointment. Appointments cancelled less than 24 hours will be charged $40 for the missed office visit. Your card on file with the office will be charged automatically for the missed visit. You are responsible for your appointment time. Text and Email notifications may be offered as a reminder of your appointments as a courtesy. Malfunctions may occur causing the notifications to not be sent out, and should not be depended on for your appointments. (Emergencies will be handled on a case-by-case basis).

Acknowledgement of Receipt of Notice of Privacy Practices: HIPAA

Renaissance Chiropractic Center uses personal information only as related to providing care and billing purposes in accordance with state and federal privacy guidelines. We do not share your information beyond what is required for these purposes.

Information and Suggestions for the Client

*Prior to your massage, remove all jewelry. Pull long hair back with clip.


*As a rule, massage is given while you are unclothed. We provide a top sheet and / or towel. Modesty and comfort levels vary from person to person. You may choose to wear undergarments or a swim suit. This is YOUR massage and you should feel as comfortable as possible.


*During your massage, you may want to give your therapist feedback as to pressure (deeper or lighter) or point out painful or ticklish areas of your body.


*Feel free to ask your therapist any questions about their procedure. 


Your therapist is a highly trained professional and will be happy to make you feel well informed and comfortable.

Informed Consent to Care

You are the decision-maker for your health care. Part of our role is to provide you with information to assist you in making informed choices. This process is often referred to as "informed consent" and involves your understanding and agreement regarding the care we recommend, the benefits and risks associated with the care, alternatives, and the potential effect on your health if you choose not to receive the care.


We may conduct some diagnostic or examination procedures if indicated. Any examinations or tests conducted will be carefully performed but may be uncomfortable.


Chiropractic care centrally involves what is known as a chiropractic adjustment. There may be additional supportive procedures or recommendations as well. When providing an adjustment, we use our hands or an instrument to reposition anatomical structures, such as vertebrae. Potential benefits of an adjustment include restoring normal joint motion, reducing swelling and inflammation in a joint, reducing pain in the joint, and improving neurological functioning and overall well-being.


It is important that you understand, as with all health care approaches, results are not guaranteed, and there is not a promise to cure. As with all types of healthcare interventions, there are some risks to care, including, but not limited to: muscle spasms, aggravating and/or temporary increase in symptoms, lack of improvement of symptoms, fractures (broken bones), disk injuries, strokes, dislocations, strains, and sprains. With respect to strokes, there is a rare but serious condition known as "arterial dissection" that typically is caused by a tear in the inner layer of the artery that may cause the development of a thrombus (clot) with the potential to lead to stroke. The best available scientific evidence supports the understanding that chiropractic adjustment does not cause a dissection in a normal, healthy artery. Disease processes, genetic disorders, medications, and vessel abnormalities may cause an artery to be more susceptible to dissection. Strokes caused by arterial dissections have been associated with over 72 everyday activities such as sneezing, driving, and playing tennis.

Arterial dissections occur in 3-4 of every 100,000 people whether they are receiving health care or not. Patients who experience this condition often, but not always, present to their medical doctor or chiropractor with neck pain and headaches. Unfortunately, a percentage of these patients will experience a stroke.


The reported association between chiropractic visits and stroke is exceedingly rare and is estimated to be related in one in one million to one in two million cervical adjustments. For comparison, the incidence of hospital admission attributed to aspirin use from major GI events of the entire (upper and lower) GI tract was 1219 events per one million persons per year and the risk of death has been estimated as 104 per one million users.


It is also important that you understand there are treatment options available for your condition other than chiropractic procedures. Likely, you have tried many of these approaches already. These options may include, but are not limited to: self-administered care, over-the-counter pain relievers, physical measures and rest, medical care with prescription drugs, physical therapy, bracing, injections, and surgery. Lastly, you have the right to a second opinion and to secure other opinions about your circumstances and health care as you see fit.

have read, or have had read to me, the above consent. I appreciate that it is not possible to consider every possible complication to care. I have also had an opportunity to ask questions about its content and, by signing below, I agree with the current or future recommendation to receive chiropractic care as is deemed appropriate for my circumstance. I intend this consent to cover the entire course of care from all providers in this office for my present condition and for any future condition(s) for which I seek chiropractic care from this office.

Thank you for taking the time to fill out this form.

Renaissance Chiropractic Center

Address

4902 Tacoma Mall Blvd.,
Tacoma, WA 98409

Phone

253-473-0300

Monday  

9:00am - 12:30pm

2:00pm - 6:00pm

Tuesday  

9:00am - 1:00 pm

3:00pm - 7:00pm

Wednesday  

9:00am - 12:30pm

2:00pm - 6:00pm

Thursday  

9:00am - 1:00 pm

3:00pm - 7:00pm

Friday  

9:00am - 12:30pm

2:00pm - 6:00pm

Saturday  

9:00am - 12:00pm

Sunday  

Closed