Confidential Intake Form
Client Confidentiality and Release Form
I understand this modality is not a replacement for medical care. The practitioner does not diagnose medical illness, disease or other physical or mental conditions unless specified under her professional scope of practice. As such, the practitioner does not prescribe medical treatment of pharmaceuticals, nor does she perform spinal manipulations. The practitioner may recommend referral to a qualified health care professional for any physical or emotional conditions I may have. I have stated all my known conditions and take it upon myself to keep the therapist/ practitioner updated on my health.
Confidentiality of medical and personal information obtained during the course of the practitioner's work is of the utmost importance. HIPAA regulations require all practitioners obtain a signed release form from their client BEFORE taking any information about them. The best way to be fully compliant is to obtain this release signature at the initial consultation. Upon request, clients can receive a copy of the form they signed, and the practitioner maintains a copy for their records
give my permission, for my practitioner to take notes including health history/ medical and/or personal information I choose to disclose to them.
JAN SCAGLIA LMT, ABDOMINAL THERAPY PRACTITIONER