Click on link below to download Client Intake Form

client_intake_form.pdf

Danielle D. Thomas LMT
Massage Policy for making appointments and what your massage entails.

When you make an appointment for a 1 or 1/2 hour massage your time begins when you enter the room.  For cash
clients, if you are late for appointment unless I have time after your scheduled time the minutes you are late you will
be included in your massage time. For patients under insurance then insurance will not be billed for missed time but
you will be bill $35.00 late fee unless there is time after your scheduled time. An intake will take place first to discuss
any issues you may have or what you are looking for in the massage it should only take a few minute unless you are
under insurance then a more through intake will be given to gather any information needed to bill insurance. Time is
also given for dressing and undressing. Also if under insurance or looking for specific treatment, time may be taken
after the massage, to do Myofascial stretching techniques, along with going over self-care for home. If you have any
question regarding my policy call 412-519-4566. Thank You Danielle Thomas

Massage is provided for the basic purpose of relaxation, stress reduction, and relief of muscular tension. Services are
designed to be a health aid and in no way are meant to take the place of a physician's care or orders. All information
exchanged and given at intake and the massage are kept confidential. Because massage should not be preformed under
certain medical conditions, intake are required for everyone. Cash, Check or Credit is accepted and payment must be
made the day of the appointment. Surcharge on returned checks of $100.00 plus court and recovery fees.

Clients must give 24-hour notice if you can not keep appointment and if 24-hour notices is not given you will be held
liable for full payment of scheduled appointment $95.00 for 1 1/2 hr. - $65.00 for 1 hour and $35.00 for 1/2 hour.

Client is responsible for full payment if insurance does not pay for treatment, also patient is responsible for $45.00 first time charge that will be used toward any deductible, copay or coinsurance, if any monies are left over I will reimburase the remainder to the patient. Arrangements must be made prior to
appointment. Client is also responsible for all co pay, coinsurance's and deductibles. Any illicit or sexually suggestive
remarks or advances made by client will result in immediate termination of the session and will be held liable for
complete payment of scheduled appointment.

Thank your for your cooperation Danielle D. Thomas LMT 412-519-4566