Massage Therapy Intake Form

Please complete this form before your first massage therapy appointment. Your information helps us provide safe and effective treatment tailored to your needs.

Takes 10-15 minutes

Secure & Confidential

Save time at your visit

Clinic Location

Which clinic location are you visiting? *

Patient Information

First Name *

Last Name *

Date of Birth *

Gender

Email Address *

Phone Number *

Street Address *

City *

Province *

Postal Code *

Occupation

Emergency Contact

Contact Name *

Relationship *

Phone Number *

Referring Physician (if applicable)

Physician Name

Physician Phone

Consent & Agreement

BACK ON TRACK PHYSIOTHERAPY - MASSAGE THERAPIST INFORMED CONSENT

As a matter of ethics and law there is an obligation, prior to examination and treatment, to disclose any material risk to the patient to obtain a valid informed consent.

As part of the massage treatments, certain procedures and devices may be utilized such as the use of heat, ice, electrotherapy, ultrasound, massage and manual therapy.

As part of the rehabilitation program (kinesiologist, occupational therapist or physical therapist assistant) certain testing procedures, devices and equipment may be utilized such as weight machines, exercise, cardiovascular work and functional tasks.

I have had the opportunity to discuss with the massage therapist and/or other clinical staff, the nature and purpose of treatments. I understand the results are not guaranteed.

I further understand, and I am informed that there are some very slight risks to treatments, including, but not limited to, muscle strains, sprains, disc injuries, and burns. I have been made aware that there are remote chances of injury and that appropriate tests will be performed to help identify if I may be susceptible to risk or injury.

Cancellation Policy

We understand that unplanned issues may come up and you will need to cancel an appointment. If this happens, we respectfully ask that you notify us at least 24 hours prior to your appointment time.

Our therapists want to be available to meet your needs as well as the needs for all of our patients. When a patient does not show up for a scheduled appointment, another patient loses the opportunity to be seen.

If we are not provided with the appropriate notice, you will be responsible for a Missed Treatment charge of $50.00.

For any Missed Massage Treatment, you will be charged in accordance with the RMTAO as follows:

2nd missed massage – 50% of the massage fee
3rd missed massage – 100% of the massage fee

This charge will not be billed to any third-party payors, you will be billed, and it must be paid by you for you to continue to be treated under your claim. Under certain circumstances management may waive this fee.

Privacy & Confidentiality

I understand that all information provided is confidential and will only be shared with other healthcare providers with my written consent, or as required by law.

My personal health information will be kept secure and used only for the purpose of providing appropriate treatment.

Consent to Share Information

I hereby consent to the sharing and/or exchange of written and/or verbal information between Back on Track Physiotherapy and the following individuals/institutions:

List full names and institutions of affiliation:

Information to be released related to the above-named injury or illness and pertains to the development of treatment and nutritional plans.

I understand that this consent is subject to revocation at any time, except for such action that has already been taken.

A photocopy of this authorization shall have the same validity as the original.

I have read and understand the above information regarding massage therapy. I consent to receive massage therapy treatment. * I acknowledge the privacy policy and agree to the collection and use of my personal health information for treatment purposes. * I have read and agree to the cancellation policy. * I certify that all information provided in this form is accurate and complete to the best of my knowledge. *

Electronic Signature (Full Legal Name) *

Date *

Your information is secure and will be kept confidential