Adobe FormsCentral

Injuries
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Nature:
Date:
Nature:
Do you have any other medical conditions? (e.g. digestive conditions, hemophilia, osteoporosis, mental illness)

YESNO
What?
Do you have any internal pins, wires, artificial joints or special equipment?

YESNO
What?
Where?
What is the reason you are seeking massage therapy?

Stress ReliefPrevention/MaintenanceProblem Correction
Please list any other reasons for seeking massage therapy:

Registered Massage Therapy Payment & Cancellation Policy
Payment is due at the time of your appointment. Please note that registered massage therapy is not covered by OHIP. However, many private health insurance plans do include coverage for registered massage therapy services. We recommend checking with your insurance provider to confirm your specific coverage details and whether a referral from a medical doctor is required for reimbursement.

If you need to cancel or reschedule your appointment, we kindly ask for a least 12 hours’ notice. Cancellation made with less than 12 hours’ notice, or missed appointments, will be subject to a $75.00 cancelation fee.

We appreciate your understanding and look forward to supporting your unique health and wellness needs and goals.
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