Submit the completed form before your first appointment. You can send the form via email to info@lowerbuckshealth.com or fax it to (215) 555-1234. For physical submission, bring it to Lower Bucks Total Health and Wellness Center, P.C., 123 Wellness Ave, Bucks County, PA 19067. We recommend filling out the form accurately to prevent delays in your treatment.

Important dates for this form include the initial appointment date and any follow-up appointments as needed in 2024 and 2025. Ensure to submit the form before the first appointment.

The purpose of this form is to gather comprehensive personal and medical information from new massage patients at Lower Bucks Total Health and Wellness Center, P.C. By providing accurate and complete details, patients help therapists to better understand their health status, specific concerns, and any pre-existing conditions. This ensures that the massage therapy provided is safe, effective, and tailored to the individual needs of each patient.

• 1. Name: The full legal name of the patient.
• 2. Address: The complete postal address of the patient.
• 3. Date of Birth: The patient's date of birth.
• 4. Email Address: The email address for contacting the patient.
• 5. Emergency Contact: Details of the person to contact in case of emergency.
• 6. Referred By: The name of the person or facility that referred the patient, if applicable.
• 7. Phone Number: Contact phone number of the patient.
• 8. Accident Information: Indication if the condition is due to a motor vehicle or work-related accident and related claim details.
• 9. Attorney Information: Name and contact number of the attorney, if applicable.
• 10. Pain/Symptoms: Mark areas of pain or other symptoms on the provided diagram.
• 11. Problem Description: Description of when and how the problem began.
• 12. Medications: List of any medications currently being taken.
• 13. Injury/Surgery: Details of any recent injury or surgical procedure.
• 14. Health Conditions: Circle applicable health conditions from the provided list and add comments if needed.
• 15. Client's Signature: Signature of the client to confirm the information is true and accurate.
• 16. CONSENT SECTION: A section for client consent to receive therapy and waiver liability.
• 17. Client's Name (print): Printed name of the client for consent.
• 18. Client's Signature: Signature of the client for consent.
• 19. Date: Date the consent was signed.
• 20. Parent/Guardian Signature: Signature of the parent or guardian if the client is under 18 years of age.
• 21. Authorized Facility Signature: Signature of the authorized facility representative.

Failing to submit this form may result in delays or the inability to provide massage therapy services.

• Inability to Provide Service: The therapist may not be able to proceed with the therapy session without the necessary information.
• Medical Risks: Lack of accurate medical information may pose health risks during the treatment.
• Appointment Delays: Incomplete submission may lead to rescheduling or delays in appointments.

• 1. New Patient Registration: For completing the initial registration process.
• 2. Medical History Update: For updating the therapist with your medical history and current conditions.
• 3. Pre-Appointment Requirement: Before you attend your first massage session.