Integrative Touch and Bodywork

Natural Pain Care
Through Massage Therapy

Patient Forms



 
Form #1
Universal Health Intake Form

All clients should download this file and complete and sign this form prior to their scheduled appointment. This form will be reviewed to better assist the therapist in accommodating the needs and expectations of the client.

Download the form



 
Form #2
Patient Report Form

All new and returning patients should fill out this form prior to each visit to help us focus your treatment to your specific goals

Download the form

Insurance Forms

All patients who have sustained injuries in a motor vehicle accident (MVA) and wish to use their PIP car insurance benefits for massage are encouraged to download these files.

Insurance paperwork can be lengthy and time consuming to fill out. It would be to the benefit of both the patient and IT&B to get a head start prior to your visit.



 
 Form #3
Prescription/Letter of Referral Form

This form should be given to your primary care provider to fill out. Insurance claims can not be submitted without this form. We will gladly send your primary care provider an IT&B prescription pad at your request.

Download the form



 
 Form #4
Insurance Questionnaire

This form allows us to verify coverage and start the billing process. Only the top portion need be completed.

Download the form



 
 Form #5
Client Pain Questionnaire

This form allows us to better understand the patient’s symptoms and the severity of the injury. Please, take the time to carefully read and sign this questionnaire.

Download the form



 
 Form #6
Assignment of Benefits

This form gives the therapist permission to bill insurance, share information with your doctors &/or lawyers, and sets up a payment plan in case insurance companies decide to default.

Download the form