Care Coordination

Consent & provider-referral form

Complete this to authorize Bourne Bodyworks to coordinate with your physician or physical therapist. Review it on screen, print it, or fill it out with us at your first visit.

Download this form (PDF)

Back to Care Coordination Intake & health history Consent & Release form

Bourne Bodyworks · 818 Industry Place, Carbondale, CO 81623 · (970) 355-8790 · bournebodywork@gmail.com

Client information

 
 
 
 
 

Provider to coordinate with

 
 
 
 
 

Authorization to exchange information

I authorize Bourne Bodyworks and the provider named above to exchange information relevant to my massage therapy and my care—including my goals, the areas and techniques being worked, my response to treatment, and any precautions, restrictions, or instructions from my provider.

I understand that: this authorization is voluntary and is not required to receive massage therapy; massage therapy is not a substitute for medical care; Bourne Bodyworks does not diagnose or treat medical conditions; and I may withdraw this authorization at any time in writing — email to bournebodywork@gmail.com is sufficient — except where information has already been shared in reliance on it. Unless I revoke it sooner, this authorization expires twelve (12) months from the date signed. Information shared with the provider named above may be re-disclosed by them and is then no longer covered by this authorization. I am entitled to a copy of this signed form.

Information may be shared by: ☐ phone   ☐ secure email/fax   ☐ written summary

 
 
 
 

If the client is under 18

 
 
 

Focus & precautions

 
 
 
 
 
 

Provider section (optional—to be completed by the physician or PT)

 
 
 
 

Note for the practice owner: this is general template language for demonstration only. Before using it with clients, have it reviewed by a qualified attorney or compliance professional to ensure it meets your state’s consent, privacy, and scope-of-practice requirements.

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