Hands Heal^™ Electronic Health Records System

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Massage Therapist Rachel Porter (Revive Therapeutics)

Personal Information

First Name *

Last Name *

Gender

Male Female Other

Address

City

State

Zip/Postal

Phone * Numbers Only

Date of Birth *mm/dd/yyyy

Email *

Confirm Email *

Create/Update User ID *

Create/Update Password *

Confirm Password *

Text Messages (optional)

Mobile Phone Numbers Only

I CONSENT to the practice contacting me by text message for the purpose of health information and appointment reminders. I will ensure that I keep the practice informed of my up-to-date mobile number at all times, or if the number is no longer in my possession.

Additional Contact Information

Emergency Contact

Name

Phone Numbers Only

Relationship to You

Select the Intake form that best represents the type of massage care you're currently seeking.

Wellness Intake

Current Health Information:

Health History:

Massage History and Goals for sessions:

Treatment Intake

Current symptoms	Yes	No	Please Describe
Aches/Pain
Stiffness
Swelling
Loss of sleep
Headaches
Numbness/tingling
Ringing in ears
Brain Fog
Allergies/Sensitivities

Other

Typical daily activities

Activities limited by current symptoms

Health Conditions	Current/Previous	N/A	Please Describe
Whiplash
Joint/Spine
Neurological/Concussions
Cardiovascular
Endocrine/Diabetes
Auto-Immune Disorders
Cancer

Other

Prescriptions/Pain medication

Surgeries or Hospitalizations: include year

Self-Care Strategies: What do you do to relieve mood, pain, and improve function?

Massage History:

Additional information requested by your therapist:

Billing and Insurance Information

Referring Healthcare Provider

Name

Phone Numbers Only

Prescription Date & #Sessions

Diagnoses/ICD-10

Primary Insurance Provider

Insurance Type

Insurance Company Name

Insurance Plan Name or Program Name

Adjuster/Contact Name

Adjuster/Contact Phone#

Extension

Company Billing Address

Company Fax

If there is no plan#/group#, put the name of the insurance company in this section

Claim# / ID#

Policy Group# or FECA#

Co-pay/Co-Insurance $

Insurance Email Address

Attorney

Attorney Name

Paralegal/Contact Name

Address

Phone Numbers Only

Fax Numbers Only

I give my consent to receive massage therapy

By checking the Consent Box, I am am agreeing to receive massage therapy for therapeutic purposes. I can have a witness present during my massage, and I'll provide the witness. If I'm under 18 years old, my parents or guardian can choose to be present during my massage. I can revoke this consent at any time.
I give my consent to receive treatment or to vary the draping protocol in these additional areas (see text box below) for therapeutic purposes

I am checking this box after the massage therapist and I have discussed the purpose, draping, and treatment plan involved.
I can revoke this consent at any time.

* Required fields

Theraphy and Patient Charting

Health Care Provider

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New Client

Referring Healthcare Provider

Primary Insurance Provider

Attorney

Attention

Theraphy and Patient Charting

Health Care Provider

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New Client

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Personal Information

Text Messages (optional)

Emergency Contact

Referring Healthcare Provider

Primary Insurance Provider

Attorney

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