Essence of Inner Peace

Forms Contact

Insurance Forms:
If you plan on using your health insurance to cover your massage sessions, you must complete the following forms.  I have provided them here for your convenience.  

Privacy Policy:

The Privacy Policy explains how medical information about you may be used and disclosed and how you can get access to this information.  You can read it online, or print it out for your records.

Health History Form:

This form is used to explain your reason for receiving massage and what kind of ailments you have or had.  This form is the only form required for first time clients who are not using their health insurance benefits. 

HIPAA Consent Form:

After reading the Privacy Policy, you would sign this form acknowledging that you have read the Privacy Policy.

Intake Form:

This form is required for insurance billing purposes.  Please fill it out completely prior to your appointment.

Patient Request for Restriction Form (optional):

This form is optional, unless you wish to restrict the uses and disclosures of your protected health information (PHI).  


Health History Form

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