New Client Information

 
 

Please answer the following questions before your first visit with Owen. You may complete this online form, or download a PDF copy and fill it out by hand.

 
Name *
Name
Today's Date *
Today's Date
Date of Birth *
Date of Birth
Best Phone(s) # *
Best Phone(s) #
Phone
Phone
Mailing Address *
Mailing Address
How did you hear about Triangle Body Therapy?
Would you like to occasionally receive news, information and special discounts from Triangle Body Therapy?
What other types of treatment have you tried to treat this issue?
What other types of treatment have you tried to treat these issues?
task or activity / duration / how often / by when
Check any which currently pertain to you:
medication / for treatment of / dose / frequency / effectiveness
medication / for treatment of / dose / frequency / effectiveness
Are you psychologically stable?
Do you exercise regularly?
mild, moderate or strenuous?
Are you currently training for an event?
Are you able to exercise now?
Do you wear:
Consent for Treatment *
I give Owen Dodge permission to provide treatment that will include "hands-on" manual therapy and instructions for my own therapeutic exercise. I understand that I am an active participant in my healing, and it is my responsibility to provide accurate and timely feedback to Owen regarding my response to treatment. If I experience pain or discomfort during the session, I will immediately inform Owen so the techniques can be adjusted to my level of comfort. I may become aware of memories and/or emotions as a result of treatment, and I am free to express them as part of my healing process. I may experience pain and/or soreness after my treatment. I understand that this is part of my healing process. I can choose to stop the treatment completely for any reason, at any time, if I so choose. I affirm that I have informed Owen of all my known medical conditions and will keep him updated as to changes in my medical condition. Owen does not diagnose any physical or psychological disorders, and nothing said or done by him should be misconstrued as such. Nor does Owen prescribe medications or perform spinal manipulations. I am responsible for consulting a qualified physician for any physical and/or psychological ailments that I may have. I understand that Owen's work should not be a substitute for this care.
Payment options *
The initial appointment costs $175. Payment is expected at the time of your appointment unless other arrangements have been made. Cash and checks are preferred methods of payment. Please make checks payable to Triangle Body Therapy. Visa, MasterCard and American Express cards as well as debit cards and HSA cards can easily be processed if they are your preference. No matter the method, many people prefer to pay at the beginning of their appointments to more fully enjoy how great they feel by the end of the session. Let Owen know if that's your preference.
Cancellation Policy *
Your appointment time is reserved exclusively for you. Please provide at least 24 hours notice in the event that you need to reschedule or cancel your appointment. If you are sick or have a fever, please reschedule. YOU WILL BE CHARGED THE FULL SESSION FEE for sessions missed for other reasons. This policy pertains to emergency cancellations at Owen's discretion.
 

When you come to Owen's office for the first time, he will ask you to make notations on a hard copy of the following image:

triangle-body-therapy-areas-of-discomfort.jpg