253-473-0300

Renaissance Chiropractic Center

253-473-0300
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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.


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Renaissance Chiropractic Center

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

Massage Intake Form

Sex*
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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.

REVIEW WAVE ELECTRONIC SIGNATURE TERMS AND CONDITIONS

Updated September 10, 2020

THESE ELECTRONIC SIGNATURE TERMS AND CONDITIONS ARE INCORPORATED BY REFERENCE INTO THE REVIEW WAVE TERMS AND CONDITIONS AND ARE LEGALLY BINDING.  By using the Review Wave E-Signature Service, you accept and agree to the terms of these terms and conditions (the "Terms").  Should any conflict arise between these Terms and the Review Wave Terms of Service (the "Standard Terms"), these Terms shall control with respect to the subject matter herein.  Both you and Review Wave may be referred to herein individually as a "Party", and collectively as the "Parties".

  1. THE E-SIGNATURE SERVICE.
    • Service Description. Review Wave's electronic signature service (the "Service") allows you to signify your agreement with legally binding agreements electronically, in lieu of a pen-and-ink signature on a physical hardcopy.  The Service is a "Review Wave Service" for the purposes of interpreting the Standard Terms.
    • Authorized Users. The Services are available only to individuals who can form legally binding contracts under applicable law.  The Services are not available to persons under the age of majority in their jurisdiction, and in no case to persons under the age of 18.  In order to use the Services, you must be identified by a unique email address.  Two or more natural persons may not use the Services using the same set of credentials.
    • Appropriate Conduct. You agree not to use the Services for any illegal or unauthorized purpose and agree to comply with all applicable domestic and international laws, statutes, ordinances, and regulations relating thereto.  You further warrant and agree that your use of the Services does not violate any relevant laws, regulations, legislation, or other applicable rules of any applicable authority.  You are solely responsible for determining the suitability of the Services for your particular purpose.

You agree not to (attempt to) modify, adapt, or hack the Services.  You agree not to engage in any activities that would create a false association with the Services.  You agree that Review Wave has sole and absolute discretion with respect to the determination of whether your use of the Services is authorized.

  • Authorized Use. You shall use the Service solely for your internal business or personal purposes, and in no case shall you make the Services or any portion thereof available to any third-party.
  1. WARRANTY DISCLAIMER AND LIMITATION OF LIABILITY.
    • Warranty Disclaimer. The Services are provided to you without warranty of any kind, whether express or implied.  REVIEW WAVE SPECIFICALLY EXCLUDES AND DISCLAIMS WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, QUIET ENJOYMENT, NON-INRFINGEMENT, AND ANY WARRANTIES ARISING OUT OF COURSE OF DEALING OR USAGE OF TRADE.

USE OF THE SERVICES IS DONE AT YOUR OWN RISK.  REVIEW WAVE ASSUMES NO RESPONSIBILITY FOR ANY LOSS OF YOUR DATA OR CONTENT OR ANY ERRORS OR OMISSIONS IN ANY CONTENT, OR FOR ANY LOSS OR DAMAGE OF ANY KIND INCURRECT AS A RESULT OF THE USE OF THE SERVICE.

  • Damages Limitation. REVIEW WAVE SHALL NOT BE LIABLE FOR ANY INCIDENTAL, SPECIAL, EXEMPLARY, OR CONSEQUENTIAL DAMAGES, INCLUDING LOST PROFITS, LOSS OF DATA, LOSS OF GOODWILL, THE COST OF SUBSTITUTE PRODUCTS OR SERVICES, OR FOR ANY DAMAGES FOR PERSONAL OR BODILY INJURY OR EMOTIONAL DISTRESS ARISING OUT OF OR IN CONNECTION WITH THESE TERMS, OR FROM THE USE OF OR INABILITY TO USE THE SERVICES, WHETHER BASED ON WARRANTY, CONTRACT, TORT (INCLUDING NEGLIGENCE), PRODUCT LIABILITY, OR ANY OTHER LEGAL THEORY, AND WHETHER OR NOT REVIEW WAVE HAS BEEN INFORMED OF THE POSSIBILITY OF SUCH DAMAGE, EVEN IF A LIMITED REMEDY SET FORTH HEREIN IS FOUND TO HAVE FAILED OF ITS ESSENTIAL PURPOSE.
  • Limitation of Liability. IN NO EVENT WILL REVIEW WAVE'S AGGREGATE LIABILITY ARISING OUT OF OR IN CONNECTION WITH THESE TERMS AND YOUR USE OF THE SERVICES EXCEED THE AMOUNT RECEIVED BY REVIEW WAVE FROM YOU IN THE SIX (6) MONTH PERIOD PRECEDING THE ACTION GIVING RISE TO THE CLAIM.  THE LIMITATIONS OF DAMAGES SET FORTH ABOVE ARE FUNDAMENTAL ELEMENTS OF THE BARGAIN BETWEEN REVIEW WAVE AND YOU.  SOME JURISDICTIONS DO NOT ALLOW THE EXCLUSION OR LIMITATION OF LIABILITY FOR CONSEQUENTIAL OR INCIDENTAL DAMAGES, SO THE ABOVE LIMITATION MAY NOT APPLY TO YOU.
  • German Customers. Review Wave's liability to you if you are domiciled in Germany is limited as follows:
    • Review Wave shall be fully liable for intentional and gross negligence, as well as for any damages arising from injury to life, body or health caused by Review Wave. In the case of liability for slight negligence, Review Wave shall be liable only for breach of a material obligation ("Cardinal Duty") and any such liability shall be limited to typical, foreseeable damages and shall not include liability for lack of economic results, loss of profit, or indirect damages. A Cardinal Duty in the meaning of this Section 2.4 is an obligation, the fulfillment of which is essential to the performance of these Terms and on the fulfillment of which the contracting party may therefore rely.
    • If you are a consumer, nothing in these Terms affects your rights under mandatory German law and these Terms will be interpreted, construed, and enforced in all respects in compliance with mandatory consumer protection laws of Germany. Notwithstanding anything to the contrary herein or within the Standard Terms, if you are a consumer, you may submit a claim to enforce your rights under these Terms to the competent courts in Germany.
  1. CUSTOMER OBLIGATIONS.
    • Personal Data. You warrant that your use and collection of any personal information or data provided while using the Services complies with all applicable data protection laws, rules, and regulations.  You acknowledge that Review Wave may process such personal data in accordance with its privacy policy [LINK TO POLICY].
    • Customer Acknowledgements and Warranties. By using the Service you consent to do business electronically.  You hereby represent and warrant to Review Wave that: a.) you have all requisite rights and authority to use the Services under these Terms and to grant all applicable rights herein; b.) you are solely responsible for all use of the Services associated with your credentials; c.) you are solely responsible for maintaining the confidentiality of your account credentials; d.) your agrees to immediately notify Review Wave of any unauthorized use of your account of which it becomes aware; e.) you agrees that Review Wave will not be liable for any losses incurred as a result of a third party's use of your Account, regardless of whether such use is with or without its knowledge and consent; f.) you will use the Services for lawful purposes only and subject to these Terms; g.) any information you submits to Review Wave is true, accurate, and correct; and h.) you will not attempt to gain unauthorized access to the Services, other accounts, computer systems, or networks under the control or responsibility of Review Wave through hacking, cracking, password mining, or any other unauthorized means.

Review Wave is not a party to any Document executed via the Services.


Review Wave has no control over the contents of any Document.  Review Wave makes no representation or warranty regarding any transaction sought to be effected by any Document.


Review Wave is not responsible or liable to determine whether any particular Document is subject to an exception to applicable electronic signature laws, or whether it is subject to any particular agency promulgations, or whether it can be legally formed by electronic signatures.


Review Wave is not responsible for determining how long any contracts, documents, and other records are required to be retained or stored under any applicable laws, regulations, or legal or administrative agency processes. Further, Review Wave is not responsible for or liable to produce any of your Documents or other documents to any third parties.


With respect to "consumers", as that term is defined under applicable consumer protection laws imposing the requirement that parties to an electronic contract consent to the method of contracting (among other requirements), Review Wave does not and is not responsible to: i.) determine whether any particular transaction involves a consumer; ii.) furnish or obtain any required consents or determine if any such consents have been withdrawn with respect to the contracting method; iii.) provide any information or disclosures in connection with any attempt to obtain any such consents; iv.) provide legal review of, or update or correct any information or disclosures currently or previously given; v.) provide any such copies or access, except as expressly provided in the Documentation for all transactions, consumer or otherwise; or vi.) comply with any such requirements.  You shall be responsible for determining if any contracting party is a consumer, and if so, to comply with all requirements imposed by law as a result thereof.


You agree that you are solely responsible for the accuracy and appropriateness of instructions given by you and your personnel in relation to the Services.


You warrant that you have the requisite authority to provide Review Wave with, and to accept from Review Wave, any required authorizations, requests, or consents, on behalf of you, your entity, and/or the entity you represent.

  1. TERM AND TERMINATION.
    • Term of Agreement. These Terms shall be effective from the moment you first access the Service until your use of the Service has completely ceased.  Review Wave may terminate or suspend your use of the Services and deny you access to its website in its sole discretion for any reason or no reason.  Review Wave may notify you prior to any such termination or suspension at its discretion.
    • Survival Provisions. The rights and obligations of the Parties under Sections 1.3, 2.1 - 2.4, 3, 4.2, 5 and 7 shall survive the expiration or termination of these Terms.
  1. INDEMNIFICATION.
    • Indemnity. You agree to release, defend, indemnify, and hold Review Wave, affiliates, and subsidiaries, and their officers, directors, employees, and agents, harmless from and against any claims, liabilities, damages, losses, and expenses, including, without limitation, reasonable legal and accounting fees, arising out of or in any way connected with your access to or use of the Service, or your violation of any term or warranty contained within these Terms.
  1. DOCUMENT RETENTION AND DATA PROTECTION.
    • Document Retention. Review Wave may store documents sent for signature via the Services ("Documents") when it is commercially reasonable to do so.  Review Wave may, at its sole discretion, delete incomplete Documents from the Services systems.
    • Transaction Data Retention. Review Wave may retain Transaction Data for as long as it has a business purpose to do so.

"Transaction Data" means metadata associated with a Document, such as transaction history, image hash value, method and time of Document deletion, sender and recipient names, e-mail addresses, signature IDs, and other unique identifiers and time/date stamps.

  • Protection of Data. You acknowledge that Review Wave has no obligation to protect your data that is stored or transmitted outside of the Services.  Review Wave will employ commercially reasonable measures to protect your data from unlawful or unauthorized access, use, alternation, or disclosure during transit and storage within the Services.
  1. GENERAL.
    • Terms. In the event that any one or more of the provisions of these Terms are for any reason held to be illegal or unenforceable in any respect, such illegality or unenforceability shall not affect the other provisions of these Terms, which shall remain in full force and effect.
    • Entire Agreement. This Agreement, the policies incorporated by reference hereto, and the agreements covering the individual services offered pursuant to the terms herein reflect the entire agreement between the parties with respect to the matters therein, and supersede all proposals, prior agreements, and commitments, whether oral or written, and all negotiations, conversations, or discussions between the Parties relating thereto.
    • Modifications. These Terms may be modified from time to time by Review Wave at its sole discretion.  Your use of the Service signifies your agreement to these changes.  You will be notified of material changes by notice on the website or via e-mail.
    • Assignment. You may not assign or delegate the rights and obligations of these Terms without the prior express written permission of Review Wave.  Review Wave may unilaterally assign or delegate the rights and obligations of these Terms at its sole discretion.  These Terms shall be binding upon and inure to the benefit of the Parties and their successors and permitted assigns.
    • Litigation of Intellectual Property. Notwithstanding the parties' decision to resolve all disputes through arbitration, either party may bring enforcement actions, validity determinations, or claims arising from or relating to theft, piracy, or unauthorized use of intellectual property in any state or federal court with jurisdiction or in the U.S. Patent and Trademark Office to protect its intellectual property rights ("intellectual property rights" means patents, copyrights, moral rights, trademarks, and trade secrets, but not privacy or publicity rights) .

 

  • Contact Information. If you have any questions, concerns, or complaints about our Services or anything under these Terms or other agreements with us, please contact us at the following email address.

Email:  support (at) reviewwave.com

Renaissance Chiropractic Center

Address

4902 Tacoma Mall Blvd.,
Tacoma, WA 98409

Phone

253-473-0300

Contact Us

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Please do not submit any Protected Health Information (PHI).

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

4902 Tacoma Mall Blvd.

Tacoma, WA 98409

253-473-0300