Physician Release Form

[beeje]

I have a potential client who has informed me of some medical issues that require a note from his physician for him to receive massage. He was quite upset that I wouldn't see him without the release form, but that's a whole nother thread. He would like me to send him a release form that he can have his physician fill out. Now, I've torn my office apart looking for this form. I have it. I've seen it. I CAN'T FIND IT! All other sorts of forms, but not the one I need today. And I thought I was good at filing.

Do any of you fine folks know where I can find a good template or something of that nature online? I've done some searching, and will continue to do so, but I'm hoping that some kind soul will nudge me in the right direction.

Thanks in advance!
Holly

 

[tay lew]

Physician Release Form

I'll have time between 3:45 & 5:30pm today (CST).. will try to look around then for you. May ahve something on the comp here at work.

 

[Pompal 09.]

Physician Release Form

Oh thank you! I'm still looking online and coming up empty handed.

 

[Rajendra M]

Sorry, but I can't find anything on the office computer at the moment and I won't be done until late this evening to look again. I've re-vamped a "consent to treat a minor" form for you, which may work until you find something better. You'll have to re-format it, as the formatting for this forum did not do it justice. Hope it helps.

• CONSENT TO TREAT CLIENT
  
  
  
  
  
  I hereby authorize , LMT, to administer massage therapy to
  
  __________________________. There are no medical issues which would hinder the client from
  (client's name)
  
  receiving massage at this time. This consent is good through
  
  ______________________.
  (date)
  
  
  
  _________________________________________
  Physician's Signature
  
  
  
  Physician's Printed Name, Address, Phone, Fax:
  
  _________________________________________
  
  _________________________________________
  
  _________________________________________
  
  _________________________________________
  
  _________________________________________

[/quote]



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Topic review - Physician Release Form






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drjohnjack






 
Post subject: 
Re: Physician Release Form
 













I've done some research on the net and found something like this as a physician release form. You might just type the "Physician Release Form" om the search engine, and you can see some pdf files. Code:Parent's name___________________________________________________________Home Phone ___________________________________________________________Address ______________________________________________________________Pediatrician's Name _________________________________Address ____________________________________________Child(ren)'s name(s)___________________________________ DOB _____________________________________________________________ DOB _____________________________________________________________ DOB __________I give permission that the above named pediatrician(s) may verify that the above listed children are currently registered patients at her or his office.____________________________Signature of Parent - Date____________________________*Signature of Physician - Date

I've done some research on the net and found something like this as a physician release form. You might just type the "Physician Release Form" om the search engine, and you can see some pdf files. [code]Parent's name___________________________________________________________Home Phone ___________________________________________________________Address ______________________________________________________________Pediatrician's Name _________________________________Address ____________________________________________Child(ren)'s name(s)___________________________________ DOB _____________________________________________________________ DOB _____________________________________________________________ DOB __________I give permission that the above named pediatrician(s) may verify that the above listed children are currently registered patients at her or his office.____________________________Signature of Parent - Date____________________________*Signature of Physician - Date[/code]











Posted: Thu Jul 08, 2010 9:24 am














swingingdelirium






 
Post subject: 
Re: Physician Release Form
 













I found these to be informative myself.

I found these to be informative myself. :D











Posted: Mon Oct 19, 2009 11:29 am














pueppi






 
Post subject: 
Re: Physician Release Form
 













I finally found the other Physican's Release Form. Just in case you need another. Quote:Rose of Sharon Therapeutic MassagePhysician ReleaseDear Physician;Your client, _________________________has chosen to receive massage therapy. Therapeutic Massage can affect all the bodyâ€کs systems. Because we understand that each client presents a unique health history with different health conditions, restrictions, precautions and recovery potential, we sometimes request a written instructions before providing any type of therapeutic massage that would increase the circulation or affect a post-surgical site. Please help us ensure that appropriate care is given to your patient by completing the release at the bottom of this page. A non-circulatory massage, Shiatsu, which is compressions along the fascial lines at a pressure enjoyed by the client, may be provided in the event that circulatory massage is medically contraindicated.Respectfully,Sharon Baker, Nationally Certified Massage PractitionerPhysician ReleaseClient Name____________________________________________________Client Signature_________________________________________________Rose of Sharon Therapeutic Massage has my permission to provide massage to this patient, with the following restrictions or precautions:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Physician’s Name:_______________________________________________(Please Print)Physician’s Signature:____________________________________________Date Signed:__________________________(contact info/address included at the bottom)

I finally found the other Physican's Release Form. Just in case you need another. :)[quote]Rose of Sharon Therapeutic MassagePhysician ReleaseDear Physician;Your client, _________________________has chosen to receive massage therapy. Therapeutic Massage can affect all the bodyâ€کs systems. Because we understand that each client presents a unique health history with different health conditions, restrictions, precautions and recovery potential, we sometimes request a written instructions before providing any type of therapeutic massage that would increase the circulation or affect a post-surgical site. Please help us ensure that appropriate care is given to your patient by completing the release at the bottom of this page. A non-circulatory massage, Shiatsu, which is compressions along the fascial lines at a pressure enjoyed by the client, may be provided in the event that circulatory massage is medically contraindicated.Respectfully,Sharon Baker, Nationally Certified Massage PractitionerPhysician ReleaseClient Name____________________________________________________Client Signature_________________________________________________Rose of Sharon Therapeutic Massage has my permission to provide massage to this patient, with the following restrictions or precautions:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Physician’s Name:_______________________________________________(Please Print)Physician’s Signature:____________________________________________Date Signed:__________________________(contact info/address included at the bottom)











Posted: Fri Oct 16, 2009 2:55 am














hollyk






 
Post subject: 
Re: Physician Release Form
 













Wonderful! Thanks so very much!

Wonderful! Thanks so very much!











Posted: Fri Jul 31, 2009 2:30 pm














pueppi






 
Post subject: 
Re: Physician Release Form
 













Sorry, but I can't find anything on the office computer at the moment and I won't be done until late this evening to look again. I've re-vamped a "consent to treat a minor" form for you, which may work until you find something better. You'll have to re-format it, as the formatting for this forum did not do it justice. Hope it helps. CONSENT TO TREAT CLIENTAddress Phone: Fax: here>I hereby authorize , LMT, to administer massage therapy to __________________________. There are no medical issues which would hinder the client from (client's name)receiving massage at this time. This consent is good through ______________________.(date) _________________________________________Physician's SignaturePhysician's Printed Name, Address, Phone, Fax:_____________________________________________________________________________________________________________________________________________________________________________________________________________

Sorry, but I can't find anything on the office computer at the moment and I won't be done until late this evening to look again. I've re-vamped a "consent to treat a minor" form for you, which may work until you find something better. You'll have to re-format it, as the formatting for this forum did not do it justice. Hope it helps. :)[list][b]CONSENT TO TREAT CLIENT[/b]Address Phone: Fax: here>I hereby authorize , LMT, to administer massage therapy to __________________________. There are no medical issues which would hinder the client from ([i]client's name[/i])receiving massage at this time. This consent is good through ______________________.([i]date[/i]) _________________________________________Physician's SignaturePhysician's Printed Name, Address, Phone, Fax:_____________________________________________________________________________________________________________________________________________________________________________________________________________[/list]











Posted: Fri Jul 31, 2009 2:14 pm














hollyk






 
Post subject: 
Re: Physician Release Form
 













Oh thank you! I'm still looking online and coming up empty handed.

Oh thank you! I'm still looking online and coming up empty handed.











Posted: Fri Jul 31, 2009 12:49 pm














pueppi






 
Post subject: 
Re: Physician Release Form
 













I'll have time between 3:45 & 5:30pm today (CST).. will try to look around then for you. May ahve something on the comp here at work.

I'll have time between 3:45 & 5:30pm today (CST).. will try to look around then for you. :) May ahve something on the comp here at work.











Posted: Fri Jul 31, 2009 12:46 pm














hollyk






 
Post subject: 
Physician Release Form
 













I have a potential client who has informed me of some medical issues that require a note from his physician for him to receive massage. He was quite upset that I wouldn't see him without the release form, but that's a whole nother thread. He would like me to send him a release form that he can have his physician fill out. Now, I've torn my office apart looking for this form. I have it. I've seen it. I CAN'T FIND IT! All other sorts of forms, but not the one I need today. And I thought I was good at filing. Do any of you fine folks know where I can find a good template or something of that nature online? I've done some searching, and will continue to do so, but I'm hoping that some kind soul will nudge me in the right direction.Thanks in advance!Holly

I have a potential client who has informed me of some medical issues that require a note from his physician for him to receive massage. He was quite upset that I wouldn't see him without the release form, but that's a whole nother thread. He would like me to send him a release form that he can have his physician fill out. Now, I've torn my office apart looking for this form. I have it. I've seen it. I CAN'T FIND IT! All other sorts of forms, but not the one I need today. And I thought I was good at filing. :oops: Do any of you fine folks know where I can find a good template or something of that nature online? I've done some searching, and will continue to do so, but I'm hoping that some kind soul will nudge me in the right direction.Thanks in advance!Holly











Posted: Fri Jul 31, 2009 12:18 pm


















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[madel]

Physician Release Form

Wonderful! Thanks so very much!

 

[Prianka]

Physician Release Form

I finally found the other Physican's Release Form. Just in case you need another.

Rose of Sharon Therapeutic Massage
Physician Release

Dear Physician;

Your client, _________________________has chosen to receive massage therapy.

Therapeutic Massage can affect all the body‘s systems. Because we understand that each client presents a unique health history with different health conditions, restrictions, precautions and recovery potential, we sometimes request a written instructions before providing any type of therapeutic massage that would increase the circulation or affect a post-surgical site. Please help us ensure that appropriate care is given to your patient by completing the release at the bottom of this page. A non-circulatory massage, Shiatsu, which is compressions along the fascial lines at a pressure enjoyed by the client, may be provided in the event that circulatory massage is medically contraindicated.

Respectfully,

Sharon Baker, Nationally Certified Massage Practitioner


Physician Release
Client Name____________________________________________________

Client Signature_________________________________________________

Rose of Sharon Therapeutic Massage has my permission to provide massage to this patient, with the following restrictions or precautions:
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

Physician’s Name:_______________________________________________
(Please Print)

Physician’s Signature:____________________________________________

Date Signed:__________________________

(contact info/address included at the bottom)

 

[Samantha J]

Physician Release Form

I found these to be informative myself.

 

[AMG]

Physician Release Form

I've done some research on the net and found something like this as a physician release form. You might just type the "Physician Release Form" om the search engine, and you can see some pdf files.

Parent's name___________________________________________________________
Home Phone ___________________________________________________________
Address ______________________________________________________________
Pediatrician's Name _________________________________
Address ____________________________________________
Child(ren)'s name(s)___________________________________ DOB __________

___________________________________________________ DOB __________

___________________________________________________ DOB __________

I give permission that the above named pediatrician(s) may verify that the above listed children are currently registered patients at her or his office.

____________________________
Signature of Parent - Date

____________________________
*Signature of Physician - Date