WSIB Intake Form

Workplace Safety and Insurance Board Client Intake Package

10-15 minutes to complete
Secure & Confidential
1

Client Personal Information

2

Extended Health Benefits

3

Cancellation Policy & Consent

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.

Signatures

By typing your name, you agree this constitutes your electronic signature

Your information is secure and will only be used for your WSIB claim processing