Welcome to our office! We are here to provide you with a safe and effective massage experience. To better serve that experience, Please read and sign the Informed Consent, Financial, Cancellation, Insurance

Verification & TIP policies. Then, please complete the following questionnaire as thoroughly as possible in order for us to understand how to best serve you. All of your answers will become a part of your confidential

records and will not be released unless you have authorized us to do so. There will be many places for your signature, please let us know if you have questions!

License MA 60149895

Your Health Information and Privacy

Our office follows HIPAA, Health Insurance Portability & Accountability Act policies. These policies dictate how medical information about you may be used and disclosed, how you can get access to this information, and how we protect your privacy. In order to maintain the level of service that you expect from our office, we may need to share limited personal medical and financial information with your insurance company¸ with other medical practitioners at your request and authorization or with worker’s compensation: and your employer in workers compensation cases.

Safeguards in place at our office include:Limited access to facilities where information is stored. Medical files kept locked and secure. Policies and procedures for handling information. Requirements for third parties to contractually comply with privacy laws. All medical files and records (including electronic medical files, email, regular mail, telephone, and faxes sent) are kept on permanent file in a secure and protected manner according to HIPAA.

Types of information that we gather and use:In administering your health care, we gather and maintain information that may include non-public personalinformation: About your financial transactions with us (billing transactions). From your medical history, treatment notes, all test results, and any letters, faxes, emails or telephone conversations to or from other health care practitioners. From health care providers, insurance companies, workman’s comp and your employer, and other third party administrators (e.g. requests for medical records, claim payment information).

In certain states, you may be able to access and correct personal information we have collected about you, (information that can identify you - e.g. your name, address, Social Security number, etc.).

We value our relationship, and respect your right to privacy. If you have questions about our privacy guidelines, please contact Melissa Heather Wolfang, LMP at (617) 543-6083.

at Kula MovementCenter for Yoga & Health

5340 Ballard Ave NWmelissaheathermassage.com

617 543 6083

Informed Consent

This disclosure is to advise you of the credentials of the practitioner, the scope of practice for Massage Therapy in the State of Washington, and to document your consent for services.

Please Read Carefully and Sign Below:

Credentials:Melissa Heather Wolfang LMP graduated from the 1020-hour program at the Center for Natural Wellness School of Massage Therapy in Albany, New York. She has held a Washington state professional massage practitioner license since May 2010. Her license number is MA 60149895. Melissa Heather Wolfang LMP maintains her license by attending 24 or more hours of continuing education biannually.

Scope of Practice: I hereby acknowledge and authorize Melissa Heather Wolfang, LMP to perform the following treatments under the scope of practice of LMP in the state of Washington. This includes, and is not limited to:

Massage and massage therapy: a health care service involving the external manipulation or pressure of soft tissue for therapeutic purposes. Massage therapy includes techniques such as tapping, compressions, friction, reflexology, Swedish gymnastics or movements, gliding, kneading, shaking, and fascial or connective tissue stretching, with or without the aids of superficial heat, cold, water, lubricants, or salts.

Intraoral massage: the manipulation or pressure of soft tissue inside the mouth or oral cavity for therapeutic purposes.

Reflexology: a health care service that is limited to applying alternating pressure with thumb and finger techniques to reflexive areas of the lower one-third of the extremities, feet, hands, and outer ears based on reflex maps.

Massage therapy does not include diagnosis or attempts to adjust or manipulate any articulations of the body or spine or mobilization of these articulations by the use of a thrusting force, nor does it include genital manipulation. Reflexology does not include the diagnosis of or treatment for specific diseases, or joint manipulations.

I recognize the potential benefits and risks of these procedures, which include but are not limited to:

Potential Benefits: Relief of presenting symptoms, relief from pain and/or tension, improved circulation, stress relief and/or relaxation.

Potential Risks: Discomfort, pain, muscular tenderness, dizziness, fainting or other bodily responses associated with general touch therapy. In the unlikely event of physical injury, immediate medical treatment will be obtained at the nearest health care facility. The costs of such emergency medical treatment will be the financial responsibility of the participant.

I have read and understand the above informed consent of Melissa Heather Massage, LLC.

Signature ___________________________________________ Date________________

Print name_______________________________________________________________

Parent or Guardian __________________________________________ Date_________License MA 60149895

Financial Policy

The following is our basic financial policy that is designed to offer you affordable quality care. Please carefully read and sign below, indicating that you agree to the policy. If you have any questions or concerns about this policy, please contact Melissa Heather Wolfang LMP.

Insurance Coverage: Insurance policies may vary greatly in terms of deductible and percentage of coverage for massage therapy. Because of the variance from one insurance policy to another, we require that you, the patient, be personally responsible for the payment of your deductible, as well as any unpaid balances in this office. We will do our best to verify your insurance coverage, and will bill your insurance in a timely manner. Our listed rates apply to the majority of patients on most visits here at Melissa Heather Massage. Charges may be higher or lower depending on time evaluation and management for individual cases. If our clinic is not notified of a change in your coverage before billing, you, the patient, will be responsible for the full amount of any appointments owed.

Preferred Provider: Melissa Heather Massage is a preferred provider with several insurance companies. We can bill in-network or out of network. Co-payments are due at time of service and patients are responsible for all fees if the claim is rejected by insurance.

Time of Service Discount: We offer a discount to all patients that pay at the time of service.

Payment Methods: We accept cash, check, debit, VISA, MasterCard, American Express & Discover.

Receipt: Upon request, we will supply you with an electronic receipt. We can provide credit card receipts and itemized insurance receipts for individuals who choose to bill their insurance separately.

Cancellation Policy:

You may cancel and reschedule your appointment at any time. If you fail to cancel or reschedule two or more office visits before the start of the scheduled appointments, there will be no option for future appointments.

Late Cancellation Policy: Late cancellations are any appointments cancelled within 24 hours of start time. For all late cancellation or any missed appointments, there will be a fee. For the first missed or late cancellation appointment there will be a 50% charge of your service. Each missed appointment or late cancellation after that will be a 100%charge of the service value.

Please Read Carefully Below and Sign:

By signing this form I agree to the above and am responsible to pay for the full treatment session that I have booked, even if I am late. I understand that I am responsible for co-payments and all fees. I acknowledge the cancellation policy that I have twenty-fours before my appointment to cancel without incurring a fee. If I have to cancel my appointment and I do not do so by twenty-four hours before my appointment time, then I will pay a cancellation fee.

I have read and understand the above financial & cancellation policies of Melissa Heather Massage, LLC.

Signature ___________________________________________ Date________________

Print name_______________________________________________________________

Parent or Guardian __________________________________________ Date_________License MA 60149895

Please sign indicating that you have answered the above questions with the help of your insurance company.

Signature ___________________________________________ Date________________License MA 60149895

Patient Insurance Verification

Our clinic is happy to use any health insurance benefit towards your massages that we can, and while we will alwaysconfirm your benefits separately, we ask that you find out what those benefits are in advance. For patients wishing touse health insurance benefits in the first month or the first two visits - whichever comes first - you must fill out the questionnaire below. Please bring a photo-copy of your current insurance card, or the physical card for us to copy, to your first appointment. As a best practice, to verify benefits, call the number on the back of your insurance card.

Insurance Information: Please write N/A for any non-applicable.

Please call your health insurance company and complete this form by asking the following questions:

Is massage covered on this plan? Are the massage benefits in-network or out of network?

Are there any deductibles which apply to massage benefits? Deductible amount: How much of deductible has been met? Any additional information about deductible:

Is pre-authorization or a referral required from my Primary Care Physician? Have pre-authorization or a referral been provided already?

Is there an any annual limit on massage benefits? Limit amount:

Is there a co-payment that I (the patient) am responsible for? Copay amount:Is there co-insurance that I (the patient) am responsible for? Co-Insurance split:

Any additional information from phone call:

$

$

$

I have read and understand the above informed consent of Melissa Heather Massage, LLC.

Signature ___________________________________________ Date________________

Print name_______________________________________________________________

Parent or Guardian __________________________________________ Date_________

I have read and understand the above TIP policy of Melissa Heather Massage, LLC.

Signature ___________________________________________ Date________________

Print name_______________________________________________________________

Parent or Guardian __________________________________________ Date_________

License MA 60149895

TIP Policy

Our clinic is grateful to you and your choice to receive regular massage as part of your wellness. The work we do in this clinic is health care and we encourage you to treat massage as part of your own health maintenance. As health providers we do not accept TIPs. Please note that we do set our own rates and would prefer that you do not tip. Instead, please use that money towards more massages, or acupuncture, etc... Thank you for your understanding.

What brings you in for massage today?

Have you had therapeutic massage before? When was your most recent massage? Have you ever received massage as part of a program, for example: under the direction of a doctor or chiropractor? If yes, please explain briefly:

If this is your first massage, please take this space to ask any questions or any concerns:

What types of pressure do you prefer?

Are you overly ticklish or sensitive in any areas?

Do you have any scars that feel uncomfortable when touched?

Have you ever received massage on your gluteal muscles?Have you had massage on your abdominal muscles?

(I.e.: Light, Medium, Firm, Deep)

Please note that gluteal and/or abdominal massage will not be preformed without prior consent.

Massage History Questions:

Personal Information:Name: Preferred Name:Name of Parent or Guardian:Street Address:City: State: Zip:Phone Number: ( ) -Emergency Contact Name: Relationship:Emergency Contact Phone Number: ( ) -

I have read and understand the above financial & cancellation policies of Melissa Heather Massage, LLC.

Signature ___________________________________________ Date________________

Print name_______________________________________________________________

Parent or Guardian __________________________________________ Date_________

License MA 60149895

Health History Questions

Medications:Please indicate any medications, vitamins, or herbal remedies you are taking and a purpose for each:

Purpose: Medication:Purpose: Medication:Purpose: Medication:Purpose: Medication:Purpose: Medication:Purpose: Medication:Purpose: Medication:Purpose: Medication:Purpose: Medication:

Date: Any Related Issues: Surgery:

Date: Any Related Issues: Surgery:

Date: Any Related Issues: Surgery:

Date: Any Related Issues: Surgery:

Date: Any Issues: Bone:Date: Any Issues: Bone:Date: Any Issues: Bone:

Date: Any Issues: Bone:

If you need extra space, please use the back of this paper.

If you need extra space, please use the back of this paper.

General Health:

Do you have any cold or flu symptoms? How long have they persisted?Please note that massage therapy facilitates the movement of fluids through the body and can sometimesexacerbate the symptoms of a cold, for one or two days after the appointment.

Have you ever had surgery?

Have you broken any bones?

Do you have any other injuries?

License MA 60149895

General Health:

Have you ever had an illness or disease? If yes, please explain:

Do you have any allergies? Do you have an epi-pen with you? If yes, please explain:

Do you have asthma? If yes, do you have an inhaler with you?

Do you have hypertension or high blood pressure? If yes, how are you regulating it?

Please use the diagram below to indicate any areas on your body you experience pain or tension. You can draw a big P for pain or a big T for tension, in order to differentiate between the two.

YES NO NOT NEEDED

YES NO NOT NEEDED

Please sign indicating that you have answered all health questions honestly, and to the best of my ability.

Signature ___________________________________________ Date________________

Print name_______________________________________________________________

Parent or Guardian __________________________________________ Date_________

License MA 60149895

For Women:Is there any chance you may be pregnant? If yes, are you trying to conceive?Please note that if you are trying to conceive massage can be helpful and supportive both in conception and during pregnancy. It is important to let your practitioners know if and when you begin to conceive or become pregnant.

Please indicate if you are on birth control, if not previously indicated in Medications: What type of birth control are you on? If you are on the implant please indicate where yours is:

Are you menopausal or perimenopausal? If yes, circle one. Please note that if you experience any affects of menopause while on the massage table, let your practitioner know so she can make necessary changes.

For Pregnant Women: How far along are you? weeks. Is this your first pregnancy? How has your pregnancy been so far and what are your concerns, if any?

The informative end, you’ve made it!Just a few things about your massage:

The massage table is equipped with a heater. It will be on low for most appointments, although it is typically off during the hot months of the summer. There will also be hot towels and stones used occasionally during your massages. Please indicate if you would not like the use of heat:

During your massage if you need anything: a tissue, to readjust something, a change in pressure, differentmusic, the bathroom, etc... please don’t hesitate to let your therapist (me) know. When you do need my attention,be sure to use words, so that I know you are signaling me and not just enjoying your massage!

Some people like to talk during massages, and that’s great! Some people don’t like to talk during massages, that’s also great! I will follow your queues on talking and if you ever want to sink in and breathe, let me know. The benefits of massage can be felt both while talking and while focusing inward. Each massage is different and you canchange your mind as often as you like.

For individuals using Personal Insurance Protection or PIP: On what date did the accident or incident occur?