Client Agreement and Contract for Care

Note you agree that it is your choice to receive massage therapy or energy work, are aware of the benefits and risks of massage and energy work, and give consent for massage or energy work. You understand there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. You acknowledge that massage and energy work are not a substitute for medical care, medical examination or diagnosis. Further, you have informed your practitioner of all medical conditions you are aware of and will inform the practitioner of any changes in your health status. You will make sound choices regarding sessions planned based upon information provided by the practitioner. You agree to communicate with your practitioner any time you feel your well-being is being compromised. You understand that in order to receive the best adjunct care possible, you will need to communicate your needs, preferences, and requests at any time before, during, or after your massage so that adjustments can be made. Your practitioner is committed to your full satisfaction and wants your honest feedback — positive or negative. Your practitioner will provide safe and effective treatment to the best of his or her skills and knowledge.

Assignment of Benefits: In the event you choose to use insurance to cover services at Arlington Therapeutic Massage and Energy Healing, you further agree that you are responsible for all charges for services provided. In the event your insurance company denies payment or makes partial payment, you are responsible for any balance due. You authorize any direct payment of medical benefits to your massage therapist practitioner for services billed.

Release of Medical Records: As applicable, you authorize the release of medical records or other health care information, including intake forms, chart notes, reports, correspondence, billing statements, and other written information to your attorneys, healthcare providers, and insurance case managers, for the purposes of processing your claims.

*Please inform your practitioner immediately upon signing any exclusive Release of Medical Records with your attorney that may impact the above release statement.