Relief Therapy - Christopher Pierce: Client Intake and Release
Your Private Health Information (PHI) is important and information submitted via this form to Relief Therapy - Christopher Pierce ("Christopher", "Chris", "I", "me") is protected under HIPAA with a BAA via Google Services. What this means is that PHI submitted in this form is kept private according to regulations under HIPAA. For more specific information and questions contact cpierce@relieftherapychicago.com or refer to https://support.google.com/a/answer/3407054.
Preferred Full Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Phone Number *
10 digit number. No symbols or spaces.
Your answer
Is it OK to text this number? *
I sometimes work with a personal booking assistant (PA) or other companies. Texts are for scheduling reminders, confirmations, etc. This is subject to your data plan.
Email
This is the email you want me to use for sending schedule confirmations, reminders, etc.
Your answer
Street Address
With unit number (outcall clients need to fill out this field)
Your answer
Zipcode
Your answer
Do you take anything regularly? *
Both every day or as needed medications should be listed, and recent use should be disclosed before the start of each session. Also list any regular injection sites (diabetes, hormones, etc.). Write "No" instead of leaving blank.
Your answer
Do you have any ongoing health concerns? *
Especially conditions related to your muscle, heart, blood, brain, or skin. Don't list past or current injuries, or temporary illnesses, here. If detailed, we can discuss more in person. Write "No" instead of leaving blank.
Your answer
Do you have any significant past or current injuries, illnesses, surgeries, or conditions not yet listed? *
This is collected for awareness of scar tissue, limited mobility, etc. You do not need to list anything which you feel fully recovered from unless it affects your movement, pain, or immune system. If detailed, we can discuss more in person. Write "No" instead of leaving blank.
Your answer
Do you have any allergies or sensitivities to oils, scents, latex, or medications? *
Medication allergies (like for penicillin) are collected in the rare case of emergencies. Write "No" instead of leaving blank.
Your answer
Contact and Billing Info *
Your privacy is important to me, and I will never sell or share your information to a third party without your consent. Because I often work with third parties, rather than making you re-enter information I already have for scheduling and billing purposes, it can be more convenient for you if I do it. However, I can not always guarantee how other parties may use that information (promotions, billing disputes, etc.), so I want to be sure you are in control. If you do not want me to share certain information preemptively, I will only reach out to you to either let me share that info, or direct you to where you can enter it yourself, as needed.
Liability Release *
for Relief Therapy - Christopher Pierce (DO NOT CHANGE)
Your answer
Legal Full Name *
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Relief Therapy. Report Abuse - Terms of Service