Transcription of Practitioner/Clinic Name: Health Information
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Practitioner/Clinic Name: Health Information
Associated Bodywork & Massage ProfessionalsMEMBERP ractitioner/Clinic Name: _____ Health Information contact Information : _____ (page 1 of 2) Client contact Information Client Name: _____ Date: _____ Date of Birth: _____ Gender: _____ Address: _____ Phone: _____ Email: _____ Referred by: _____ Emergency contact : _____ Phone: _____ Physician/ Health -care Provider name: _____ Phone: _____ Is this massage/bodywork medically necessary (is it for a medical condition, injury, surgery)? Yes No Do you have a physician referral/prescription? Yes No Are you seeking insurance reimbursement? Yes No If yes, please complete the Billing Information form. Type of insurance coverage for this claim: Car Collision Worker s Compensation Private Health Massage Information Have you ever received professional massage/bodywork before?
Associated Bodywork & Massage Professionals MEMBER Practitioner/Clinic Name: _____ Health Information Contact Information: _____ (page 1 of 2) Client Contact Information
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