Billing Authorization I, understand that all insurance billing is done by Massage in LA at 337 S. Beverly Dr. Suite 102 Beverly Hills, CA 90212. All scheduled insurance appointments will be processed unless cancelled 24 hours prior to scheduled appointment time. Each massage session will start once both client and massage therapist are ready. Arriving late to your scheduled appointment will cut into the time of your session. Signature: [signature* signatureNewClient cols:300] Billing Authorization I, understand each massage session will start once both client and massage therapist are ready. Arriving late to your scheduled appointment will cut into the time of your session. Confidential Client Information DOB:Month123456789101112/Day12345678910111213141516171819202122232425262728293031/Year2000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901 Sex: FemaleMale Address: City: State: Zip Code: Phone Number: Email address: Name of school attending: Insurance: UNITEDCIGNA Insurance ID Number: Areas of complaint: NECKMID-BACKLOW-BACKHIPSSHOULDERS Signature: [signature* signature cols:300] Customer Satisfaction Survey On a scale of 1-5, please rate your experience based on the following criteria (1= Needs Improvement, 5= Exceptional) Date: Massage Therapist: Client Name: Scheduling the Appointment: 12345 Attention to Problem Area: 12345 Desired Pressure: 12345 Professional & Kind Attitude: 12345 How was the temperature of the room? 12345 Would you recommend your therapist to others? 12345 What can we do to improve your experience? Did your therapist tell you about our yelp page? NoYes Get free body scrub Make sure to CHECK-IN on yelp to recive a BODY SCRUB on your next appointment! LET EVERYBODY KNOW HOW YOU ENJOYED YOUR MASSAGE. Existing Client First Name: Last Name: Phone: E-mail: DOB:Month123456789101112/Day12345678910111213141516171819202122232425262728293031/Year2000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901 UNITED or CIGNA: ID Number: Signature: [signature* Signature cols:300] Massage in LA - New Client Billing Authorization I, understand that all insurance billing is done by Massage in LA at 337 S. Beverly Dr. Suite 102 Beverly Hills, CA 90212. All scheduled insurance appointments will be processed unless cancelled 24 hours prior to scheduled appointment time. Each massage session will start once both client and massage therapist are ready. Arriving late to your scheduled appointment will cut into the time of your session. Date: Date: Signature: [signature* Signature] Although we work hard to make sure the billing is accurate, we cannot always guarantee that it will be error-free. If you have ANY questions regarding your billing for any reason, please contact us HERE at Massage in LA so we can research and correct it with your insurance carrier. Thank you! Confidential Client Information First Name: Last Name: DOB:123456789101112/12345678910111213141516171819202122232425262728293031/2000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901 Anniversary:123456789101112/12345678910111213141516171819202122232425262728293031/20162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916 Phone Number: Cell Phone Carrier: Email: Occupation: How did you hear about us? Preferred Pressure: LightLight-MediumMediumMedium-HeavyHeavy Preferred Type of Massage: Deep TissueSwedishThaiSportsMedicalHot StonesRolfingWatsuReikiCranialLymphaticThoracic Reason for visit: —Please choose an option—RelaxationPain ReliefRelaxation & Pain Relief Allergic/sensitive to oils or creams? YesNo Are you pregnant? YesNo Are you under 18 years old? YesNo Please list any medical conditions (ie. Cancer, TMJ syndrome, skin disorders etc.) that could affect your massage: Please list past accidents and surgeries: Are you comfortable with having therapeutic massage on the following areas: Gluteal Region: YesNo Pectoral Muscles: YesNo Scalp: YesNo Face: YesNo Abdomen: YesNo Feet: YesNo Here at Massage in LA, we follow a strict set of guidelines intended to provide a safe professional environment for our guests, members and workers. Please let management know immediately if you have any concerns about your session or massage therapist. Male/female genitalia and women’s breasts will not be exposed at any moment in the massage. If you feel uncomfortable at any moment during the session, request your therapist to end the session immediately. It is your responsibility to inform us of any existing conditions, disabilities or sensitivities and to inform your therapist if you feel any discomfort during the massage. Because therapeutic massage/bodywork should not be performed under certain circumstances, you affirm that you have stated all medical conditions of which you are aware and will inform your practitioner of any changes in my medical status. You understand that therapeutic massage/bodywork should not be construed as a substitute for medical examination, diagnosis or treatment. We may, in our sole discretion, refuse or discontinue massage services if we determine such services may be unsafe or cause discomfort to you. The undersigned acknowledges he/she has read and undersigns this disclaimer. Date:
