Patient Forms

All forms are in Word 2010 format. Please bring them with you at the time of your first visit. Alternatively, you may complete these forms when you arrive at the clinic for your initial visit. All required forms must be completed before your session begins.

You can save your completed forms and email them to admin@mbmyoskeletal.com.  However, this method is NOT recommended because email is not a secure medium and is NOT HIPAA compliant! All your information, once in our hands, will be kept strictly confidential.

Please read all forms carefully before signing.

New Patients: Please complete Forms A, B, C.  If patient is a minor, also complete Form E.

Insurance Patients: Please complete Form F.

Returning Patients: No forms are necessary if your last visit was within the past 6 months.  If your last visit was more than 6 months ago, please complete Form B again, even if there were no significant changes in your health.

If you want Manchester-Bedford Myoskeletal LLC to release any portion of your clinic file: Please complete Form D.  Please understand that no confidential information will be released to anyone without this completed form.

Form A – MBM Policies – Please print & sign

Form B – Patient Health History – Please print this form, fill out completely, sign & date. Note: This non-fillable form replaces the old fillable version.

Form C – Informed Consent for Therapeutic Massage – Please print this form, sign & date

Form D – Medical Records Release Form – Please complete this form if you want us to release any portion of your file to your designee

Form E – Minor Informed Consent – Please complete this form if patient is a minor

Form F – Financial Agreement – Please fill in your name on the three blank lines in the letter body, sign and date at the bottom. To leave your credit card information on file for convenience, please fill in the remainder of the form with your card information. If you opt not to leave credit card information on file, you will be billed

Click here to view our Notices of Privacy Practices. You may print a copy for your records. You may obtain a copy from our office upon request.