Q1 2023 Request to Book

Availability Form - Q1 2023

We will check your availability form against our upcoming openings and contact you when we have appropriate treatment times.
Name*

First Name Last Name
Visit History*
Phone Number
Email*
example@example.com
Gender Identity

MaleFemaleNon Binary
Prefer to specify:
Pronouns

She/HerHim/HisThey/ThemOther
Please note our hours vary slightly from week to week, but we are generally open from 8AM-2PM
Indicate Day Availability (we are closed Wednesdays, weekends and holidays)*

MondayTuesdayThursdayFriday
Indicate if there is a specific time that works best for you, or if you prefer Early Morning (8-10AM), Late Morning (10-12) or Afternoon (12-2PM)*
If you have a rotating/inconsistent schedule or prefer to list specific dates of availability, please do so here:
Select Treatment Frequency Preferences*
Select Applicable Insurance Coverage

Pacific Blue CrossManulifeCanada LifeICBC/WCBOtherNone/Private Pay
Select Treatment Goals*

Injury RehabTreatment of headaches/migrainesPreventative/MaintenanceAnxiety Reduction/Stress ManagementGeneral tensionImprove flexibilityImprove sleep qualityOther
Is there a specific injury or area of of concern that you are seeking treatment for?
Should be Empty:

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Availability Form - Q1 2023