Medical History

Step 1 of 4

Basic Info

Patient First Name *

First Name

Patient Last Name *

Last Name

Patient Preferred Name

Preferred Name(if different)

Patient Pronouns

Pronouns

Patient Date of Birth

Patient Gender *

Gender

Contacts

Email *

Mobile Phone *

A mobile phone is required if you would like to receive SMS appointment reminders.

Home Phone

Address

Street Address *

Suite Number

City *

Province *

Postal Code *

Guardian(For Customers Under 18)

First Name

Last Name

Cell Phone

Relationship

Emergency Contact(For Cusotmers 18+)

First Name

Last Name

Cell Phone

Relationship

How did you hear us?

General Intake Form & Consent

and above date)

Accuracy of Information

I certify that the above medical information is correct to my knowledge. *

I agree *

I confirm that the above information is accurate and true to my knowledge. I understand that the client/therapist relationship will be held with complete confidence and any and all information I provide will only be shared upon my written consent. I hereby release the practitioners at Therapeutic Body Concepts from any and all liability should any problems arise from the treatments I receive due to any incorrect information I have given, or any information requested in this health history that I withheld. I certify that the above medical information is correct to my knowledge.

Privacy and Sharing of Information

I authorize the clinic to collect my info *

I agree. *

I authorize the clinic and its associated health professionals to collect my personal and medical information as documented above. In addition, I authorize the clinic and its associated health professionals to communicate with my family doctor and/or referring doctor as deemed necessary for my beneficial treatment. I also understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission.

Informed Consent for Treatment

consent to receive treatment *

I agree. *

I hereby request and consent to the performance of one, or more of the following therapies: Massage Therapy, Acupuncture, Herbal Therapy, Reflexology, Reiki, Manual Osteopathy or others offered at Relax & Recover. These therapies will be performed by registered and licensed practitioners. I understand that results are not guaranteed. I further understand that I am informed, as in all health care, in the practice of the above-mentioned therapies that there may be side effects (post treatment soreness, redness, etc.). I wish to rely on the therapist to exercise judgement during my treatment plan. By signing below, I agree to the above-named therapies. This consent form will cover the entire course of treatment for my present condition(s) and for any further condition(s) which I seek treatment for. I am aware that I may withdraw this consent and stop treatment at any time. I give my informed consent to receive treatment at Relax & Revoer.

Credit Card Policy

Our office is pleased to offer direct billing to your Extended Health Benefit Provider. To offer this service, we require a valid Credit Card on file for any charges not covered by your Benefit Provider. Please note that your credit card will not be charged for the outstanding balance until the insurance company has responded and/or paid their portion to Therapeutic Body Concepts. Our office will always contact you with the amount to be paid prior to charging your card. We will either call and speak with you if possible, or leave a voicemail message. By signing this, you agree that you understand that your credit card number will be stored 100% securely on file with Therapeutic Body Concepts for future transactions on your account. This includes No Show and Late Cancellation Fees. You may cancel this authorization at any time by contacting our office. This authorization will remain in effect until cancelled.

Authorize the credit card to be charged. *

I agree *

I hereby authorize my credit card to be charged by Therapeutic Body Concepts for any balances on services rendered and/or No Show and Late Cancellation Fees. I acknowledge that I have read all above statements and agree to the contents. I do not wish to Direct Bill my Extended Health Benefits, or I do not have an Extended Health Benefit Plan.

Payment Collection Policy

We would like to inform you that in the event your benefits, motor vehicle insurance, or any other form of payment does not cover the full cost of the treatment, we will make every effort to contact you via phone and email for a period of one month (30 days) following the service date. If we are unable to reach you, or if the outstanding amount remains unpaid after this time, we will send your account to a Collections Company directly. Please be advised that by receiving our services, you are consenting to this policy. We appreciate your understanding and cooperation in this matter.

I have read and understand this payment collection policy *

I have read and understand this payment collection policy

Basic Info

Contacts

Address

Guardian(For Customers Under 18)

Emergency Contact(For Cusotmers 18+)

Credit Card Info

Cancellation & Missed Appointment Policy

Questionnaires

Please let us know what your primary concern and reason for seeking treatment:

Please check off all applicable boxes below (past and current):

General Intake Form & Consent

Accuracy of Information

Privacy and Sharing of Information

Informed Consent for Treatment

Credit Card Policy

Payment Collection Policy