Alliance Massage Intake form

Informed Consent to Massage Therapy Treatment
Welcome to Alliance Physio! To ensure that you receive the safest and most effective care and that you understand the treatment you will be receiving, please review the information provided below.
- I understand that the massage therapist must obtain personal information and informed consent prior to a massage therapy treatment
- I have reviwed the attached privacy regarding collection, use, and disclosure of my personal information and I understand that steps have been taken to ensure my privacy. I understand how the privacy policy applies to me and I have had an opportunity to ask for clarification
- I agree that the RMT may collect, use and disclose my personal information for clinica purposes
30 MINS $70

45 MINS $85.00

60 MINS $110.00

I understand that if I do not provide 24 hours notice or do not call and reschedule my appointment, I will be charged for the treatment at that time allotted to me.

By signing this document, I acknowledge that I have read and understand the above statement and agree to treatment based on this document. I consent to massage therapy treatments provided by an RMT at Alliance Physio
Client Name
Client Signature

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Personal Health Information Act - Privacy Policy
As a Registered Massage Therapist, I am responsible for collecting, utilizing, and disclosing your personal information with your written consent. This information may only be used for the purpose for which it was collected. For example, I may use your information to contact you regarding appointments and to provide you with information on other services. If I desire to use this information for other purposes, I must obtain your consent.

Personal health information is collected to assess your health needs, offer options for treatemtn, and to then provide such treatment. This information also provides a baseline health information from which I may form a safe and effective treatment plan and may identify changes over tiem. I am also required to report any serious misconduct or incompetence of another practictioner.

The College of Massage Therapists of Ontario requires me to collect information and keep records. As part of their regulatory activities, they may review my recrods for completeness. In addition, Canada Customs and Revenue Agency, Information and Privacy Commissioner and the Human Rights Commission may examine my records. In the case of a third party coverage of Massage Therapy (i.e. WSIB, Private Insurance etc), your consent is implied and legistlative authority is addressed to me to collect and disclose the required information to demonstrate the clients entitlement to funding.

Your health information is protected in a locked cabinet. I am required to maintain my client records for minimum of 10 years after the last contact with a client. This enables me to respond to any questions or concerns from the client or other agencies. Following the 10 year period, I may destroy the file in a secure manner.

With only a few exemptions, the lcient has the right to see what personal information I have collected regarding your history and care. You may also ask to have a mistake corrected-this applies to factual information or to perfessional opinions that may have formed. In some instances, documentation to confirm changes may be required. If there is a disrepancy, then you may wish to include a statement in your life.

Anytime I need to forward information to a third party, I must obtain your written consent and do my utmost to ensure the information is delivered in a secure manner.

Should you have any questions or concerns, do not hesistate to discuss them with me. Any further information on the privacy act may be obtained at www.privcom.gc.ca.
Personal Information
Name

First NameLast Name
Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Occupation
Date of Birth

MonthDayYear
Date
Email
example@example.com
Family Physician
Family Physician Phone Number
Emergency Contact
Emergency Contact Phone Number
How did you find out about us?
Insurance Company
Member Name
Plan Number
ID Number
YesNo
For relaxation or other reason?
Current medications
Conditions it treats:
YesNo
If yes, for what?
Have you had any surgeries? When?
Have you had an injury? When?
Do you have any other medical conditions?
YesNo
If yes, what?
If yes, where?
What is the reason you are seeking massage therapy?
ArmsUpper BackMid BackNeckLower BackDegenerative DiscsFeetHandsHipsJawKneesLegsOsteoarthritisRheumatoid ArthritisShoulders
FaintingDizzinessLoss of sleepFatigueNervousnessNumbnessTinglingParalysisHeadaches (tension)Migraines
HepatitisTuberculosisHIVHerpesAthlete's FootWartsOther
RashesItchingBruise EasilyDrynessBoilsOther
High BPLow BPCoronary Heart DiseaseHeart AttackPhlebitisStroke/CVAPacemakerHeart MurmurPalpitationsVaricose VeinsSwelling in anklesPoor circulationSinus Infections
Poor apetiteGasConstipationDiarrheaNauseaUlcerVomiting
AllergiesHearing Aids/LossVision Loss
PregnantPainful MenstruationHeavy flowIrregular FlowMenopausalPre-menopausalBirth Control
Chronic coughBronchitisAsthmaSmokerEmphysemaPneumonia
Yes
If yes, where?
Yes
If yes, please indicate your onset
Yes
If yes, what type of hypersensitivity?
What type of reaction do you experience to hypersensitivity?
EpilepsyCancer
What type of cancer?
YesNo
Please specify
I attest that the information I have provided is true and complete to the best of my knowledge. I understand this information to be confidential and will not be released without my written consent. I consent to therapeutic massage therapy by any RMT at Alliance Physio.
Signature

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Date

MonthDayYear
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Alliance Physio Cancellation Policy
We require a minimum of 24 hours notice for change or cancellation of an appointment. This will enable us to fill the time slow you have vacated with another patient in need of our care.

The cancellation fee is equal to the full fee for the appointment time you have booked.

We understand that last minute changes in your schedule are somtimes impossible for you to avoid. Should you arrive late for your appointment or request to leave early, the full fee for the appointment will be charged.

We will attempt to remind you of your appointment a day in advance, however please note this service as a courtesy. Please DO NOT reply on these calls to keep track of your appointments. A cancellation fee equal to the full fee for the appointment for you also apply for missed appointments.

PLEASE NOTE: We understand that your time is valuable and therefore we make every effort to keep our schedule running on time. Due to the nature of our work, unexpected delays sometimes occur. Please be assured that under these circumstances you will receive your full treatment.

I understand the above and agree to abide by this policy.
Signature

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Date

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Payment Policy and Insurance Coverage
Fees for services or products are covered by most extended health plans. Each plan can vary greatly as to the amount covered per treatment and the yearly maximums covered. As a policy holder, it is your responsibility to contact your insurance company and confirm the exact details of your coverage. Please note that we may do direct billing for certain insurances/plans, but any differences that are not paid it is the responsibility of the patient to pay. All WSIB cases that are approved are billed directly to WSIB and payment will then be received from WSIB. All MVA charges will first be billed towards your private insurance and then the difference will be billed to your car insurance (based on FSCO rules If direct billing is not allowed please note it will be your responsibility to bring the payment to the clinic with the statement attached. Payment is due in full by cash, debit, visa, mastercard at the end of every treatment session if it is not covered by insurance or direct billing is not allowed. A receipt with all the required information will be provided to you, which you can then submit to your insurance company for

I understand the above and agree to abide by this policy:
Patient or Guardian/Parent Signature

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Date

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Should be Empty:

Informed Consent to Massage Therapy Treatment

Personal Health Information Act - Privacy Policy

Personal Information

Alliance Physio Cancellation Policy

Payment Policy and Insurance Coverage