Maplecare_Bank_Massage_Therapy_Form

Massage Therapy Patient Form for Bank Street Location

Please complete this form to the best of your ability. If something does not apply to you, put NA as the answer.
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender

Other
Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Province
Postalcode
Email
example@example.com
Telephone (C)
Format: (000) 000-0000.
Telephone (H)
Format: (000) 000-0000.
How did you hear about us?

Other
If referred by a Doctor, please state name:
Emergency Contact
Full Name
Relationship
Telephone
Format: (000) 000-0000.
Care Provider Information
Family Doctor Name
Telephone
Format: (000) 000-0000.
Fax
Referring Doctor Name
Telephone
Format: (000) 000-0000.
Fax
Health Status & Medical History
Main Massage Related Concern
How long have you been dealing with this pain/concern?

Current level of pain (choose one)

Rows	No Pain	0	1	2	3	4	5	6	7	8	9	10	As painful as it gets
Level

Past Medical History (select all that apply)
Please list other conditions here:
Medical Notes
Are you taking blood thinners?
Are you taking any antibiotics for an infection?
List all medications you are currently taking
List any surgeries you have had
Billing and Financial Agreement
Do you have any private healthcare coverage?
Name of Insurance Company
Policy Number
Claim Number (if applicable)
Credit Card Information
Card Type

Other
Card Holder Name
1st 8 digits of card number
last 8 digits of card number
Expiry
cvv
I consent MapleCare Physiotherapy to charge my credit card
Informed Consent & Policies (please read completely)
MapleCare Physiotherapy Clinic is my health information custodian.

I give consent to the Registered Massage Therapists (RMTs) and other clinicians at MapleCare Physiotherapy Clinic for assessing and treating my condition(s) who may use techniques that require them to place their hands on my body.

I understand that my practitioner may need to communicate with my physician and/or other health care professionals regarding my condition and treatment, for which I give consent.

A minimum of 24- Business hour notice is required for cancelling an appointment. I am subjected to a fee of $75.00 for no-show or cancellations made in less than 24 hours.
Client or Guardian Signature

Clear
(Please write Client/Guardian Full Name which serves as electronic signature)
Date

MonthDayYear
Date
Should be Empty: