Forms for Massage
Step 2: Decide how you will be paying for your massage.
Optional: Click Here for Page Contents a list of all the available forms furnished by our office.
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Leilani took this picture at the Mt. Vernon Orchid Show Feb. 2007.
Everyone start with:
Decide how you will be paying for your massage.
Options for payment are
"Same Day Pay" = you are planning to pay check, cash or use Paypal.com at the time of your massage.
OR "Billed / Insurance"
= you are planning to have our office bill your insurance company for your
payment for your massage.
2nd: Pick your column
Same Day Pay Column 2
Billed/Insurance Column 3
3rd: If you want you can fill out your forms and bring them to your massage session, saving you time!
Please do not forget to bring your forms with you or you will just have to fill them out again when you arrive.
Thank you for your patience and thoroughness with your forms. This process helps us save you time and process your bills.
Leilani took these pictures at the Mt. Vernon Orchid Show Feb. 2007.
Same Day Pay
If you are planning to pay by check,
cash, or use your debit or credit card to pay for your massage
B. Click here for privacy - I have read, print, and fill out.
C. Click here for Medical History, print, and fill out
D. Bring completed forms to your
appointment or scan and then email them to leilani @ leilanimassage.com.
You're ready for your massage appointment !
is a copyright photo of one of Leilani's
Billed / Insurance
If you are having our office bill your insurance company or attorney or third party for your massage, please print and fill out only the forms in this column that apply to you & your insurance company.
Please read all the way through to see if each item applies or not A through H.
* Then click here for privacy permission, print, and fill out.
We may need to verify your insurance. Please either call 206-914-3885 or email leilani @ leilanimassage.com the information listed on this form click here for the insurance verification form.
This way we can make sure you have massage benefits and whether or not you need a referral from your doctor prior to your appointment. You may also have to pay a deductible, copay or coinsurance at the time of your massage. These details of the insurance plan are decided by your insurance plan and your plan selection. If you want more details, please feel free to call us or your insurance plan directly.
C. Click here for Medical History Intake form, print, and fill out the form.
D. Referral or prescription
Almost all insurance plans require a referral or prescription for massage therapy treatment.
Prior to your appointment, please either call to your doctor's office or your insurance to confirm the insurance company has received the referral/prescription from your doctor or plan to bring it with you to your massage appointment.
If you do not have a referral/prescription, click here for a blank referral form, print it, and have your doctor fill it out for you.
E. Please click Health Status Update, print, and fill out the form.
Only if applicable to your condition/pain, please click
Neck Pain Index
AND/OR Low Back Index
AND/OR Headache Index, print, and fill out
the indexes that apply to your pain/condition(s).
*ONLY auto accident or on the job injury incident clients, please REMEMBER to bring your claim information including the insurance company's telephone number and your claim number. You will definitely need referral for treatment see D above.
H. ONLY if you are a Group Health patient, if not skip to I.
*ONLY Group Health Patients, please complete the following form: click here for the FRI form, print it, and fill it out.
I. Please remember to bring your completed forms to your appointment or scan and email them to leilani @ leilanimassage.com.
Now you're ready for your massage appointment !