• Please check off any of the conditions below that you are experiencing, have experienced, or a close relative has suffered from:
  • Other Conditions
  • Loss of sensation
  • Allergies/Hypersensitivity
  • Arthritis
  • Women
  • General Health Questions
  • Surgeries
  • Injuries
  • 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: