(717) 533-6100 info@madchirowellness.com
  • Facebook
  • Google
  • Facebook
  • Google
  • Schedule an Appointment
Madeira Chiropractic Wellness Center and Laser Pain Relief Center
  • Home
  • New Practice Members
    • Schedule an Appointment
    • What Makes Us Different
    • How To Choose the Best Chiropractor
  • Online Forms
  • Services We Provide
    • Exceptional Chiropractic Care
    • Chiropractic Care for Women, Babies & Children
    • Laser Pain Relief Therapy
    • Therapeutic Massage
    • Anti-Aging & Wellness Products
    • Work from Home Wellness™
  • Patient Education Videos
    • Our YouTube Channel
  • Patient Reviews
  • About Us
    • Meet Our Team
    • Our Mission
    • Hours & Directions
    • Contact Us
    • Write a Review for Us!
    • Photo Gallery
    • Career Opportunities
    • Special Messages
Select Page
 

Step 1 of 4

25%
  • Client Information

  • General Information

    In order to plan a massage session that is safe and effective, please complete the information below. Please answer the questions to the best of your knowledge.
    Please select all that apply.
    Please Select All That Apply
  • Medical History

    In order to plan a massage session that is safe and effective, please complete the information below.
    Please Select All That Apply
  • Notices & Informed Consent


    Draping will be using during the session- only the area being worked on will be uncovered.

    Clients under the age of 18 must be accompanied by a parent or legal guardian during the entire session. Informed written consent must be provided by parent or legal guardian for any client under the age of 18.

    I understand that the massage I receive is provide for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the massage therapist updated as to any changes in my medical profile and understand that there shall be no liability on the massage therapist’s part should I fail to do so.
  • This field is for validation purposes and should be left unchanged.

 

  • Legal
  • Privacy
  • Patient Reviews
  • Write a Review for Us!
  • Schedule an Appointment
  • Special Messages
  • Staff
Copyright © 2021 Madeira Chiropractic Wellness Center, Inc. All rights reserved.
We use cookies on our website to give you the most relevant experience by remembering your preferences and repeat visits. By clicking “Accept”, you consent to the use of all the cookies.
.
Cookie SettingsAccept
Privacy & Cookies Policy

Privacy Overview

This website uses cookies to improve your experience while you navigate through the website. Out of these cookies, the cookies that are categorized as necessary are stored on your browser as they are essential for the working of basic functionalities of the website. We also use third-party cookies that help us analyze and understand how you use this website. These cookies will be stored in your browser only with your consent. You also have the option to opt-out of these cookies. But opting out of some of these cookies may have an effect on your browsing experience.
Necessary
Always Enabled

Necessary cookies are absolutely essential for the website to function properly. This category only includes cookies that ensures basic functionalities and security features of the website. These cookies do not store any personal information.

Non-necessary

Any cookies that may not be particularly necessary for the website to function and is used specifically to collect user personal data via analytics, ads, other embedded contents are termed as non-necessary cookies. It is mandatory to procure user consent prior to running these cookies on your website.