Adobe FormsCentral

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

YES NO
What?
Do you have any internal pins, wires, artificial joints or special equipment?

YES NO
What?
Where?
What is the reason you are seeking massage therapy?

Stress Relief Prevention/Maintenance Problem Correction
Please list any other reasons for seeking massage therapy:

Fee and Cancellation Policy
All payments will be due upon services rendered. Massage is not a benefit of OHIP. However, many private Health Insurance Policies include Massage Therapy coverage (e.g. PSHP, formerly GSMIP). Twelve hours notice is required for cancellation of your appointment otherwise you will be billed a treatment fee of $50.00.
Consent Policy
Consent Policy
Your comfort and trust in this clinic is very important. You are encouraged to actively participate by communicating before during and after therapy about any aspects of the treatment. The massage therapist respects your right to give informed and voluntary consent regarding care and treatment before providing treatment and that you have the right to make changes regardless of prior consent given.

Signature*:______________________________________________________

Date*___________________________________________________________

*note: you will be asked to sign at your 1st visit at the clinic when we print a physical copy of this questionnaire
Should be Empty: