Massage Therapy Intake History Form

Respiratory - chronic cough       shortness of breath       bronchitis       asthma       emphysema      

Cardiovascular - high blood pressure       low blood pressure      CCHF       heart attack       stroke/CVA       phlebitis       pacemaker or similar device  

Other conditions - loss of sensation       diabetes       allergies (ie. anaphylaxis or skin irritation)       cancer       epilepsy  

Infections - hepatitis       TB       HIV      

Head/Neck - vision problems       vision loss      ear problems       hearing loss      

Soft tissue/Joint discomfort - neck       low back       mid back       upper back       shoulders       arms       legs       knees       other  

I, __________________________________________________ consent to the treatment as described and explained to me by my therapist. I acknowledge that my therapist has provided me with information pertinent to the treatment and agree to receive it. I understand that my therapist will collect personal information as an individual practitioner to provide massage therapy, to help assess health care needs, make recommendations and to establish a baseline of healthcare information. I understand that the Massage Therapist will retain this form for 10 years from the last contact as regulated by the College of Massage Therapists of Ontario.

Privacy Policy: Your knowledge and consent are required before we may collect, use, or disclose your personal information except in rare circumstances (i.e. subpoena, medical emergency, and debt collection). If you have a question on any of this, please ask our office manager.

Massage Treatment Entails: Assessment, reviewing the health history form with your therapist, massage and self-care advice at the end of the treatment.

First Visit: Your RMT will review your Health History form with you and will ask questions to ensure that you receive a treatment that meets your needs. You will be asked to update this form yearly for address changes and any health-related changes that you're Registered Massage Therapist (RMT) should be aware of.

Illness If you have a fever or a cough related to flu or cold symptoms, please call and reschedule your appointment. Massage is contraindicated for fevers and can exacerbate flu-like symptoms. Please leave a message for your therapist if you need advice.

Soft Scent Policy Please refrain from using large amounts of perfumes, other scented products and refrain from smoking at least an hour before appointment.

Cell Phones We ask that you do not make or receive phone calls on portable devices while in the clinic.

Lateness Policy Clients are responsible for the time they reserve for their appointment. If you are late for your appointment the treatment will still end at the designated time with no change in fee.

CANCELLATION/MISSED POLICY The Pickering Wellness Centre has a cancellation policy, when you book an appointment with a therapist you are booking that therapist's time. In order to accommodate all our clientele, we need 24-hour notice of cancellation, less than that is inadequate time for us to offer your appointment time to others. If you are unable to make it, we request that you call 24 hours in advance. If you do not call to cancel before the 24-hour period, a cancellation fee will be charged.

The fees for cancellation are as follows:

** All cancellation fees are subject to HST. If you book within the 24hr time frame, the policy is in effect immediately.

I understand the 24-hour cancellation policy and agree to pay the missed appointment fee if I cancel within the 24-hour period preceding my appointment time. I understand Pickering Wellness lateness policy that I am responsible to pay for the time I reserved with the therapist, regardless of the time I arrive, and I am ready for my appointment.

Thank you for your consideration and cooperation.