January 2015

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Cancellations and Late Arrivals

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Cancellation Policy
We understand that unanticipated events happen occasionally in everyone’s life. In our desire to be effective and fair to all clients, the following policies are honored:

24 hour advance notice is required when cancelling an appointment. This allows the opportunity for someone else to schedule an appointment. If you are unable to give us 24 hours advance notice you will be charged the full amount of your appointment. This amount must be paid prior to your next scheduled appointment.

Anyone who either forgets or consciously chooses to forgo their appointment for whatever reason will be considered a “no-show.” They will be charged for their “missed” appointment.

Late Arrivals
If you arrive late, your session may be shortened in order to accommodate others whose appointments follow yours. Depending upon how late you arrive, your therapist will then determine if there is enough time remaining to start a treatment. Regardless of the length of the treatment actually given, you will be responsible for the “full” session. Out of respect and consideration to your therapist and other customers, please plan accordingly and be on time.

We look forward to serving you!

Physician Permission Form

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Associated Bodywork & Massage Professionals

Practitioner/Clinic Name: Veda King Blanchard/Rooted Arts

 Contact Information: (862)202-6948; rootedarts@gmail.com

Patient Information

Patient Name: _________________________________ Date of Birth: ______________

Permission Granted to

Provider Name: _______________________________

Specialty/Type of Treatment: ________________________

Reason for Permission

There is no reason to believe that massage or bodywork treatments will harm this patient’s progress.

However, please  note the following considerations:____________________________

Description of condition:______________________________________________

Possible interactions with medications:_____________________________________

Special instructions:__________________________________________________

Permission Granted by
Physician/Health-Care Provider Name:


Phone: ________________________ Fax: ________________________

Email: __________________________

Signature: ___________________________________ Date: __________________
Please note: Should you notice anything unusual or significant during treatment, please notify this office immediately. Otherwise, any update at the conclusion of care would be appreciated.

First Time Client Form

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Associated Bodywork & Massage Professionals MEMBER

Practitioner/Clinic Name: Veda King Blanchard/Rooted Arts
Contact Information: (862)202-6948; rootedarts@gmail.com

Client Contact Information
Client Name: ___________________________________ Date: ____________
Date of Birth: ____________ Gender: ____________

Address: _________________________________________________________________________

Phone: _______________________________________

Email: ___________________________________

Referred by: ___________________________________

Emergency contact: ____________________________

Phone: ___________________________________

Physician/Health-care Provider name: __________________________ Phone: ____________________
Is this massage/bodywork medically necessary (is it for a medical condition, injury, surgery)? Yes ☐ No ☐
Do you have a physician referral/prescription? Yes ☐ No ☐

Massage Information
Have you ever received professional massage/bodywork before? Yes ☐ No ☐
How recently? ___________________________________
What types of massage/bodywork do you prefer? ___________________________________
What kind of pressure do you prefer? Light Medium Firm
What are your goals/expected outcomes for receiving massage/bodywork?



How do you feel today?

List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):


Do these symptoms interfere with your activities of daily living (e.g., sleep, exercise, work, childcare)? Yes No

List the medications and supplements you currently take:

Are you wearing contacts? Yes ☐ No ☐
Are you wearing dentures? Yes ☐ No ☐
Are you wearing a hairpiece? Yes ☐ No ☐
Are you pregnant? Yes ☐ No ☐

Health History
Have you had any injuries or surgeries in the past that may influence today’s treatment?


Circle any of the following health conditions that you currently have (If you are unsure, please ask):

blood clots, infections, congestive heart failure, contagious diseases, pitted edema

Please answer honestly, as massage may not be indicated for the above conditions, and may, in some cases, be dangerous.
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received:
Current Past Muscle or joint pain _____________________________________
Current Past Muscle or joint stiffness _____________________________________
Current Past Numbness or tingling _____________________________________
Current Past Swelling _____________________________________
Current Past Bruise easily _____________________________________
Current Past Sensitive to touch/pressure _____________________________________
Current Past High/Low blood pressure _____________________________________
Current Past Stroke, heart attack _____________________________________
Current Past Varicose veins _____________________________________
Current Past Shortness of breath, asthma _____________________________________
Current Past Cancer _____________________________________
Current Past Neurological (e.g. MS, Parkinson’s, chronic pain) _____________________________________
Current Past Epilepsy, seizures _____________________________________
Current Past Headaches, Migraines _____________________________________
Current Past Dizziness, ringing in the ears _____________________________________
Current Past Digestive conditions (e.g. Crohn’s, IBS) _____________________________________
Current Past Gas, bloating, constipation _____________________________________
Current Past Kidney disease, infection _____________________________________
Current Past Arthritis (rheumatoid, osteoarthritis) _____________________________________
Current Past Osteoporosis, degenerative spine/disk _____________________________________
Current Past Scoliosis _____________________________________
Current Past Broken bones _____________________________________
Current Past Allergies _____________________________________
Current Past Diabetes _____________________________________
Current Past Endocrine/thyroid conditions _____________________________________
Current Past Depression, anxiety _____________________________________
Current Past Memory Loss, confusion, easily overwhelmed _____________________________________


________________________________________________________________________________Consent for Treatment

If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage/bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. Understanding all of this, I give my consent to receive care.

Client Signature: _____________________________________________________________

Date: ____________

Parent or Guardian Signature (in case of a minor): ___________________________________

Date: ____________


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All energy is one.

I call this one God.


I am God


Mothers leaning over newly met babes are God richly steeped in joy. New shoots poking forth from ground and branch in early spring are God joyfully bursting with excitement. I admire, I grow, I am God expressed in Joy. I am Joyful.


I release my joy into infinite God knowing as I do that it is so.


And so it is.