4250 8th AVE NW, Suite 100  Seattle, WA 98107
509 Olive Way, Suite 1342  Seattle, WA 98101
2119 17th AVE S  Seattle, WA 98144
TEL:  206.718.5002  FAX:  206.568.7405

Date _______________________________Referred by: _____________________________
Name: First, Middle and Last __________________________________________________
Street Address____________________________ City/State______________ Zip____________
Phone: Hm_____________________ Wk______________________ Cell_________________ Email Address______________________________________Birthday: ____________________ Age______________ Occupation _____________________
SS# _________________________ Driver’s License __________________________________
Emergency Contact ____________________ Phone ___________ Relationship ___________
Name of Referring Provider __________________________ Phone # ____________________
Address_______________________________________________________________________
Fax# ____________________________
Your Insurance Information
Type of Insurance:  Auto _____ Health ______ L&I/Worker’s Comp _____ PIP ________NA_____
Insurance Company _______________________________________________________________
ID#___________________ Group #_____________________ Phone #_______________________
PIP Claim # __________________ Claims Adjuster _____________________ Phone # __________
L&I Claim #_______________________ Claim Manager________________ Phone # ___________ Insured’s Address __________________________________________________________________ 
Insured’s Employer ______________________ Address________________________________
______________________________________________________________________________
Patient Responsibility/Authorization of Release of Medical Benefits
 I agree to the release and use of my information for medical and/or insurance billing purposes and authorize Jenny Eggers to obtain any information from my healthcare providers concerning my health. 
I authorize payment of medical benefits to Jennifer Eggers for Massage Therapy services.
I am aware, that I am fully responsible for all health care bills for services rendered regardless of determination by insurance company.		
I appreciate you rescheduling your appointment as soon as you realize you are not able to keep it. I may ask you to pay a $30 cancellation fee if cancelled at the last minute. 

Client/ Guardian Signature __________________________________________________________ 
Date ____________________

PLEASE TAKE THE TIME TO ANSWER THE FOLLOWING QUESTIONS AS THOROUGHLY AS POSSIBLE.
 
Health History:
Onset date of Current Injury/Pain  ____________________________________________________ 
Describe in your own words your health and health goals in the space below: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Do you have any chronic/ongoing conditions that you deal with on a regular basis?
i.e. Muscle Spasms, Headaches, Digestive Issues, Achy Joints, Mood Disorders etc….
Explain: ___________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________ 
Please list self-care routines, including stress reduction, exercise routine, and frequency: 
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
List and Explain
Surgeries/Injuries/Breaks/Auto Accidents/Head Trauma/Headaches
Include dates and treatment received:
 ________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________ _________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Major Illnesses:  _____________________________________________________________
________________________________________________________________________________________________________________________________________________
List current medications (include pain relievers, herbal remedies, and supplements): _______
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Are you currently seeing a doctor for any reason? Explain: ___________________________
________________________________________________________________________________________________________________________________________________

I understand that massage practitioners do not diagnose illness, disease, or any physical or mental disorder; nor do they prescribe medical treatment, pharmaceuticals, or perform spinal thrust manipulations. 
I have stated all medical conditions that I am aware of and will update the massage practitioner of any changes in my health status.
SIGNATURE & DATE:

*Check all CURRENT and PREVIOUS Conditions.  Explain And Include Dates*
MUSCULO-SKELETAL	SKIN
_____neck/head pain____________________________	_____rashes_________________________________
_____headaches/head injuries_____________________	_____boils__________________________________
_____jaw pain/ TMJ ____________________________	_____fungal infections________________________
_____shoulder/arm pain_________________________	_____athletes foot____________________________
_____thoracic outlet/carpal tunnel_______________		_____herpes simplex__________________________
_____wristt/hand pain___________________________	_____lice or mites____________________________
_____low back/hip pain_________________________	_____warts_________________________________
_____knee, ankle injuries/pain____________________	_____eczema________________________________
_____foot pain/bunions__________________________	_____psoriasis_______________________________
_____plantar fascitis____________________________	_____open wounds/sores______________________
_____ORTHOTICS___________________________	_____scars__________________________________	
_____whiplash________________________________	_____other__________________________________
_____spasms/cramps___________________________	NERVOUS SYSTEM
_____sprains/strains____________________________	_____ALS__________________________________
_____bone or joint disease______________________	_____multiple sclerosis________________________
_____bone fractures____________________________	_____Parkinson’s disease______________________
_____osteoporosis_____________________________	_____numbness/tingling_______________________
_____joint dislocations_________________________	_____herpes zoster___________________________
_____rheumatoid arthritis_______________________	_____post polio syndrome_____________________
_____arthritis________________________________	_____dizziness/ringing in ears__________________
_____tendonitis_______________________________	_____loss of memory/confusion_________________
_____bursitis_________________________________	_____sciatica/shooting pain____________________
_____hernia__________________________________	_____chronic pain____________________________
_____spondylosis____________________________		_____depression_____________________________
_____ankylosing spondylitis_____________________	_____other__________________________________
_____fibromyalgia_____________________________	RESPIRATORY/CARDIOVASCULAR
_____gout___________________________________	_____anemia________________________________
_____bone spurs______________ ________________	_____thrombophlebitis________________________
_____other___________________________________	_____hemophilia_____________________________
DIGESTIVE		_____high/low blood pressure__________________
_____abdominal pain__________________________	_____varicose veins__________________________
_____GERD(reflux)___________________________	_____clotting disorders________________________
_____Crohn’s diseasse_________________________	_____heart disease___________________________
_____irritable bowel syndrome___________________	_____swollen ankles__________________________
_____constipation_____________________________	_____poor circulation_________________________
_____gas/bloating_____________________________	_____irregular heart beat______________________
_____diverticulitis_____________________________	_____asthma________________________________
_____gall stones_______________________________	_____emphysema____________________________
_____ulcers__________________________________	_____chronic bronchitis_______________________
_____hepatitis________________________________	_____shortness of breath_______________________
_____candidiasis______________________________	_____sinusitis_______________________________
_____other___________________________________	_____allergies_______________________________
URINARY/REPRODUCTIVE		_____other__________________________________
_____kidney disorders_________________________	LYMPH/IMMUNE
_____bladder disorders_________________________	_____edema/swelling_________________________
_____urinary tract infection_____________________	_____mononucleosis__________________________
_____endometriosis____________________________	_____lupus_________________________________
_____ovarian cysts____________________________  	_____chronic fatigue syndrome_________________
_____prostate_________________________________	_____HIV/AIDS_____________________________
_____painful menstruation______________________ 	_____chronic inflammation____________________
_____are you pregnant/trying?___________________		_____other auto-immune disorders_______________
_____other___________________________________	_____other__________________________________
OTHER
_____diabetes________________________________	_____cancer/tumors__________________________
_____nicotine/caffeine addiction_________________	_____drug/alcohol addiction___________________

I understand that massage practitioners do not diagnose illness, disease, or any physical or mental disorder; nor do they prescribe medical treatment, pharmaceuticals, or perform spinal thrust manipulations. 
I have stated all medical conditions that I am aware of and will update the massage practitioner of any changes in my health status.
SIGNATURE & DATE:

BILLING INFORMATION REQUEST FORM
In order to fully understand Massage Therapy coverage under your insurance plan, we have developed this questionnaire to be completed PRIOR to your first visit.
NOTE: You are responsible for obtaining this information from your insurance company. We thank you for your assistance in this matter.

• Insurance plan name or program name: ________________________________________________
• Member ID #: _______________________Group # _____________________________________
• Customer Service Phone #:  (_______)_________________________________________________
• Name of customer service representative: ______________________________________________
• Insurance claim address: ____________________________________________________________
• Date eligibility began: ______________________________________________________________
• Deductible: $_________Co-pay: $__________Co-insurance: $________
• Maximum allowable benefit for Massage Therapy: $________ # visits __________
• Remaining $_______# visits ________ for current year as of ____________________
• Does this plan require a referral from your primary care physician to/for Jenny Eggers/Massage 	Therapy for payment of services?  YES _________NO__________
	OR, 
	IS A PRESCRIPTION REQUIRED? YES __________ NO ____________

• How frequently does the referral/prescription need to be updated to ensure continuous coverage? 
(i.e., every 2 weeks, every month, every three months, etc.) _______________________________
• If your company is an HMO or PPO, and Jenny Eggers is NOT a provider for the plan, what is
	the benefit coverage? (i.e., 60%, 80%, etc.).

Additional Information: