J Rose Massage
Providing the massage you want and deserve.
Client Forms


First-time Client Health History form-Everyone must fill this out at your first visit to our office. You may either arrive early for your appointment to fill it out or fill it out ahead of time & bring it with you. The minor consent at the bottom is required to be signed by a parent or guardian of anyone under 18.
Return Client Change Form- Fill this form out ahead of time if some significant information has changed.
 Body Map for Clients- You may want to fill this form out if you have multiple challenges or think you may forget to tell our therapist about something important.
Client Feedback form-please fill this out every time you come in so that we can know how well we have done in meeting your needs and expectations. We also offer online reviews on Facebook and by email after your appointment.
Physician's Permission form-We ask that anyone with ongoing medical treatment for illness or severe injury get this form filled out by your doctor before your visit. We look out for the safety of our clients. We are not doctors, so we want to make sure that your challenges will not pose further health issues if massage is used.
Physician's Referral form- For doctors to refer patients to our office. It is helpful in cross-office communication. Many insurance companies, injury or work-comp claims require a copy of this form before they will reimburse the cost of your massages.* Please supply your practitioner with a copy as well if you decide to seek reimbursement from any of these sources so that he or she can provide the therapies prescribed.

 

*Note: We do not bill insurance. Any communication with insurance or claims for reimbursement must be done by the client.


 

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