zenith_Massage_Intake

PHYSIOTHERAPY CHIROPRACTIC MASSAGE I LASER THERAPY CUSTOM ORTHOTICS SHOCKWAVE THERAPY
MASSAGE THERAPY INTAKE INFORMATION
PART A
Name

First NameLast Name
Date of birth

MonthDayYear
Date
Address
City
Prov
Postal Code
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email Address
example@example.com
Consent to receive email/Text notifications
Emergency Contact:
Phone #
Do you have an extended Health Benefit

YesNo
If Yes, Please Specify
Part B:

Informed Consent to Massage Therapy I understand that the message therapy to be provided is for relief of muscular tensions, spasm or pain, stress reduction and to improve blood circulation to the muscles. I understand the Massage Therapists do not diagnose illness, disease or physical disorders, and they do not prescribe medical/ pharmaceutical treatment.I understand that massage is not a substitute for medical examination or diagnosis and it is recommended to see a physician for any ailment that I may have.
Patient Signature

Clear
Date

MonthDayYear
Date
Time
Part C: Health History
Have you ever been treated for any of the following? (Please select all that apply)

StrokeHeart diseaseRheumatoid ArthritisEpilepsyRespiratory ProblemsDiabetesMigraineHemophiliaHepatitis AHepatitis BHepatitis CHIV,Other
Do you have any of the following? (Please select all that apply)

Dizzy Spells,FracturesCardiac PacemakerMetal Implant in the body
Are you pregnant or do you think you might be pregnant? Please select as applicable

YesNo
Part D: Massage Therapy Fees

The purpose of this page is to clarify your financial responsibilities. All Fees includes applicable GST.

I have read, understood and agreed to the fees and payment obligations as listed above.
Patient Signature

Clear
Date

MonthDayYear
Date
Part E: Clinic Policy

Appointments Cancellations and Rescheduling:

We require at least 24 hours notice for any cancellation or to reschedule your appointment. Patients areliable for a fee of $25.00 for each canceled or missed appointment without the required notice.

We do our best to accommodate all our patients, however, late arrivals may result in reduction of treatment time. In this case, the full fee may be charged. Late cancellation/No-show fees are charged to the patient. We can not charge these fees to your benefit provider.

Insurance Coverage and Your financial Responsibilities:

In all cases, the patient is responsible for the full payment of services at the time services are rendered. If you have extended health care coverage, they may cover some or all the treatment cost. We will try to direct-bill your insurance provider. However, some plans may not allow direct billing, so please check with your benefits administrator for more information. You will be responsible for immediate payment of full costs not covered by your policy or for full costs where direct billing is not accepted by your policy provider. For your convenience, we accept Cash, Debit, Visa and MasterCard.

Safety:

Children must be under adult supervisor and are not to play with any equipment Please notify your treating therapist of any change in your condition, you have started a new medication or anything you are unsure about

Please notify your therapist immediately if you are in any discomfort during your treatment

If you have inhalers or nitro spray or other emergency medication, please have it with you at all times while in the clinic

Food and Drinks:

No food or drinks are allowed inside the clinic at any time.

Telephone calls:

We kindly ask that you turn off or put your cell phones in silent mode to ensure a private and comfortable treatment environment.

Lost or Stolen Items:

We are not responsible for any items lost or stolen while attending our facility.
Lastly, who can we thank for referring you to us?

My Physician referred me to Zenith PhysioPrevious Zenith Physio patientLaw FirmAdvertisement/SignageInsurance CompanyNewspaper Ad/NewsletterWebsite/Facebook/Google SearchOther Local Services/BusinessesSignageOther
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MASSAGE THERAPY INTAKE INFORMATION