Client Forms

NEW CLIENT FORMS: 
Please email a clear photo of the front of your ID and complete the Health History Form (attached below) before your appointment.
This helps me prepare for your session and ensure your care plan is safe, personalized, and accurate.
Email forms to: kacijoneslmt@gmail.com 

Massage Intake Form- This form gathers important information about your health, medications, injuries, and goals for massage therapy. It helps me tailor your treatment and keep your session safe and effective.

Pediatric Client Intake & Parental Consent Form
For patients under 18, this form collects important health, developmental, and comfort information to help plan a safe, age-appropriate massage session. It must be completed and signed by a parent or legal guardian before your child’s first visit, as required by Tennessee law.

Office Policies- Review and sign this form before your first appointment — it covers cancellation, billing, and communication policies to keep your care smooth and transparent.

Returning or Follow-Up Visits:

Screening Questionnaire form- Used to update your file if your health status changes between visits — quick and easy check-in to keep your care current.
Health Status Update- For returning clients, this short form helps track progress and note any changes in pain, stiffness, or mobility since your last visit. It ensures your treatment plan continues to match how your body feels today.

As Needed (Medical or Insurance Clients)

Physician's Permission form- If you’re under medical care (such as post-surgery, cancer treatment, or certain conditions), your physician can use this form to confirm that massage therapy is safe for you. 
 

Physician's Referral form- Required if your massage will be billed to an insurance company (such as post-accident or medical massage). This ensures medical necessity and speeds up the claim process.
 

Billing Information form- Needed for insurance or MVA claims. Includes your claim number, insurance details, and referring provider information.