My name is Daniel Ruscigno, and my company ClinicSense

helps massage therapists automate their administrative tasks

(scheduling, intake forms, note-taking, invoicing, and more) so

they can spend less time on paperwork and more time doing

the things they love.

When you start using clinic management software you will:

- Save yourself time from tedious admin work

- Feel the relief of being more organized

- Put more money into your pocket

But, just in case you’re not yet using ClinicSense, I wanted to

find a way to provide you with some value as well :) On the

following pages you will find paper templates for:

• Intake form

• Consent form

• COVID-19 Prescreening form

• SOAP note for pain

• SOAP note for relaxation

• Sensitive area consent form

• Cancellation policy

• Gift certificate promotion template

• Gift certificate template

• Retention email template

• Introduction letter to other healthcare professionals

subjective

Client Name Date

Therapist Name Duration Of Treatment

Sensation of pain:

Dull Cold

Sharp Burning

Tender Aching

Itching Sensitive

Cramping Radiating

Throbbing Shooting

Tingling Pressure

Stiff

Other

Was there a specific incident that cause this pain?

Motor vehicle accident Fall

Slept funny Work related

Sports/exercise

Other

Intensity of pain: (circle one)

When did the pain start:

Primary area of pain:

Adhesion Spasm

Rotation Inflammation

Pain Trigger point

Tender Point Elevation

Hypertonicity

Time pattern of pain

Constant (pain does not change)

Intermittent (intensity doesn’t change but comes & goes)

Variable (intensity changes throughout the day)

Pain/discomfort is brought on or made worse by...

Pain/discomfort feels better with…

Does this pain prevent you from participating in…

Work Leisure activities

Sports/exercise Sleep

Other

Page 1 of 2

1 62 73 84 95 10

Have you seen other practitioners about this issue?

Massage therapist Physical therapist

Chiropractor Physician

Other

sOAP NOtes

Spine

Normal

Lordosis [ mild moderate severe ]

Kyphosis [ mild moderate severe ]

Scoliosis [ mild moderate severe ]

RaNge Of mOTION

Area

Full range Moderate restriction

Slight restriction Severe restriction

Area

Full range Moderate restriction

Slight restriction Severe restriction

Areas treated

Back

Neck

Shoulders

Feet

Hip area

Other

Techniques used

Swedish

Deep tissue

Hot stone

Intra-oral

Shiatsu

Other

Abdominals

Chest

Face

Arms

Legs

Reflexology

Trigger points

Stretching

Hydrotherapy

Thai massage

PalPaTION

Area

Tension [ mild moderate severe ]

Texture [ pliable adhesive fibrotic ]

Tenderness [ mild moderate severe ]

Temperature [ normal increased decreased ]

Area

Tension [ mild moderate severe ]

Texture [ pliable adhesive fibrotic ]

Tenderness [ mild moderate severe ]

Temperature [ normal increased decreased ]

Pelvis

Normal

Tilt [ mild moderate severe ]

Twist [ mild moderate severe ]

Protract [ mild moderate severe ]

Retract [ mild moderate severe ]

Shoulders

Normal

Tilt [ mild moderate severe ]

Twist [ mild moderate severe ]

Protract [ mild moderate severe ]

Objective

treAtmeNt

POSTuRe aSSeSSmeNT

AssessmeNt PlAN

How did the client respond to treatment? Treatment plan and self-care recommendations:

Informed consent received

sOAP NOtes Page 2 of 2

Client Name Date

Therapist Name Duration Of Treatment

PRE-TREATMENT

Thinking about the past week, how would you rate your level of stress?

Not at all stressed

Somewhat stressed

Very stressed

Thinking about the past week, how would you rate your quality of sleep?

Excellent

Good

Fair

Poor

Additional information provided by the client:

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

Therapist observations and results of physical examination:

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

POST TREATMENT

How would you rate your current level of relaxation?

Not at all relaxed

Somewhat relaxed

Very relaxed

Additional information provided by the client:

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

Page 1 of 2

SOAP NOTE fOr rElAxATiON

TREATMENT PLAN

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

Page 2 of 2SOAP NOTE fOr rElAxATiON

Date of initial visit How would you rate your general health?

Excellent Good

Fair Poor

Have you had a professional massage before?

Yes (Date of last treatment)

No

Page 1 of 2

First Name Date of birth

Last Name Referred by

Email Address Mobile Phone #

Home Phone # Work Phone #

Street Address City

State Zip Code

Emergency contact name Physician’s name

Emergency contact relationship Physician’s phone #

Emergency phone #

List current medications & the conditions they are treating

Please tell us about any allergies or hypersensitivities Reason for initial visit

List any major accidents or surgeries (including dates)

intake form

CardiovasCular

High blood pressure Low blood pressure

Heart attack Stroke

Heart disease Poor circulation

Phlebitis / varicose veins Pacemaker

Hemophilia

Chronic congestive heart failure

Family history of cardiovascular problems

skin & infeCtions

Hepatitis HIV / AIDS

Herpes Tuberculosis

Lyme disease Infectious skin conditions

other Conditions

Cancer Diabetes

Unexplained weight loss Digestive conditions

Fibromyalgia Chronic fatigue syndrome

Depression Anxiety

Psychiatric disorder

Other conditions

head neCk

Headaches / migraines Vertigo / dizziness

Ringing in ears Hearing loss

Vision problems Vision loss respiratory

Asthma Shortness of breath

Chronic cough Bronchitis

Emphysema Sinusitis

Frequent colds Smoker

Family history of respiratory difficulties nervous system

Sensory loss / change Numbness / tingling

Sciatica Epilepsy

Seizures Multiple sclerosis musCuloskeletal system

Arthritis Family history of arthritis

Osteoporosis Tendonitis

Bursitis Jaw pain (TMJ)

Pins / plates / wires / artificial joint

reproduCtive

Pregnant Given birth

Gynecological problems

intake form Page 2 of 2

I hereby certify that the above information is accurate and true

Signature: ______________________________________________________________________________ Date: _________________________

CONSENT FORM

It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage.

I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis.

I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status.

I understand that my personal health information will be collected. I understand that all information that I provide will be kept confidential unless required by law. I understand and consent that my medical information may be shared by the various care providers involved in my care and treatment.

Treatments may be covered by extended health care plans. I understand that it is my responsibility to confirm the exact details of my coverage.

Signature: __________________________________________ Date: _________________________

I, ________________________ (name), have requested assessment and/or treatment by this therapist

________________________ (name) for treatment of the clinically relevant areas indicated below (please initial):

______ Chest Wall Muscles (not including breasts)

______ Breast (s)

______ Buttocks (gluteal muscles)

______ Upper Inner Thigh(s)

List Clinical Indication: _____________________________________________________________

The therapist has explained the following to me and I fully understand the proposed assessment and/or treatment: • The nature of the assessment, including the clinical reason(s) for assessment of the above area(s) and the draping methods to be used • Theexpectedbenefitsoftheassessment • The potential risks of the assessment • The potential side effects of the assessment • That consent is voluntary • That I can withdraw or alter my consent at any time.

I voluntarily give my informed consent for the assessment and/or treatment as discussed and outlined above.

Client Name (print): _____________________________________________________________

Client Signature: _________________________________________Date: _________________ Ongoing Treatment:I am aware that the treatment of the above indicated area(s) is part of a treatment plan which has been discussedwithmebymytherapist.Iconfirmthat,onthefollowingdate(s),thetherapisthasreviewedthe treatment plan and I provide my informed consent.

Client Signature: ____________________________________Date: _______________

Client Signature: ____________________________________Date: _______________

Client Signature: ____________________________________Date: _______________

Client Signature: ____________________________________Date: _______________

CONSENT TO ASSESSMENT & TREATMENT OF SENSITIVE AREA

Signature

Date Time

I agree that I am not currently experiencing any of these symptoms:

• Cough •Shortnessofbreathordifficultybreathing • Fever •Chills • Sore throat •Newlossoftasteorsmell

Please note: Otherlesscommonsymptomshavebeenreported,includinggastrointestinalsymptomslikenausea,vomiting, or diarrhea.

HaveyoutestedpositiveforCOVID-19? HaveyouknowinglybeenexposedtosomeonewithCOVID-19? Haveyourecentlytraveledtoanareawithahighinfectionrate? Haveyoubeeninanareawheresocialdistancingwasnotproperlyobserved? Haveyoubeentoanursinghome?

Ifyouhaveexperiencedanyoftheabove,pleaseprovidemoredetailastodatesofinfection,contactwithpersonexposedetc.

COVID-19 PRE-SCREENING

YES NO

Please be aware of our 24-hour cancellation policy.

Because it is difficult to fill a cancelled appointment without sufficient notice,

appointments cancelled without 24 hours notice and missed appointments will be charged

a fee of $_______.

If you need to cancel your appointment, please call or email us at least 24 hours in advance.

We can be reached at _____________________or via email at ____________________________.

Thank you!

I,_____________________________________________, have read and agree to the above policy.

cancellation policy

Signature _____________________________________________________ Date ________________________

RETENTION EMAIL TEMPLATE

Good morning ___,

I hope that you are doing fantastically well!

I noticed that it’s been _____ months since your last appointment and wanted to reach out in case any aches or pains have crept up in that time, or maybe you’re just looking to treat yourself to a little bit of “me” time and schedule a relaxation massage.

I’d love to see you soon. If you’d like to book an appointment, here’s a link to my online scheduling so you can see my availability: ____________.

Have a great day!

GIFT CERTIFICATE PROMOTION EMAIl TEMPlATE

Good morning __________________________,

I hope your day is off to a great start…and I’m also hoping that my email makes it a little bit better!

I’m emailing today to let you know that I’m offering ________% off on gift certificates until ____________________. So if you’re looking to treat yourself, a family member, or a friend, this is a great chance to lock in some savings.

If you’d like to take advantage, you can conveniently buy a gift certificate online and it will be emailed to you. Here’s the link to my online gift certificates:______________________

Have a great day and hope to see you soon!

Gift certificate teMPLate

GIFT CERTIFICATEClinic Name: _____________________________________________________________________

To: ______________________________________________________________________________

From: ____________________________________________________________________________

Amount: _________________________________________________________________________

Date Issued: ______________________________________ Expiry: _______________________

Authorized Signature: _____________________________________________________________

GIFT CERTIFICATEClinic Name: _____________________________________________________________________

To: ______________________________________________________________________________

From: ____________________________________________________________________________

Amount: _________________________________________________________________________

Date Issued: ______________________________________ Expiry: _______________________

Authorized Signature: _____________________________________________________________

Copy attributed to AMTA

IntroductIon letter

Clinic Name: ______________________________________________

Clinic Address: ____________________________________________

Date: ______________________________

Dear Dr. ___________________________,

My name is ________________, and I am a licensed massage therapist. [I am new to your area/We are sharing a patient for the first time], and I wanted to tell you a little bit about myself and the kind of work I do in the hope that we may work together. It is my intention to support your health care plan and to provide quality care to your patients.

I have experience in actively participating with health care teams and am able to communicate through standard forms of documentation. Enclosed are sample copies of my charting and report writing style. I am committed to keeping my referring physicians apprised of their patients’ progress.

My specialty is [headaches]. I have attended advanced study courses on this condition and have taken a particular interest in [headaches related to whiplash trauma]. Recently published results of research regarding the efficacy of massage on patients with headache pain report [cite research and summarize its results]. I am also highly skilled in [working with a variety of musculoskeletal dysfunctions].

I have enclosed a brochure that describes my practice and services, and the fees for various services. I have included information about the benefits of massage therapy specific to conditions your patients might experience.

Professionalism, communication, and quality health care are my strengths. [Please call me if you wish to /I will call your office in two weeks to] discuss any of this information in more depth, or if any of your patients have the need for an exceptional massage therapist.

I look forward to working with you.

Yours in health,

Once you’re ready to take the next step in your business, I’d like to invite you to join ClinicSense.

We’re generally helping save an hour per day from admin work, which allows you to spend more

time with your clients or on growing your business.

We offer a 14-day free trial (with no credit card required) so you can see how ClinicSense works.

START FREE TRIAL

next StepS