Massage Therapy

Massage Therapy Intake Form

Please complete this form prior to your first appointment. Your information will be kept strictly confidential.

Takes 5-10 minutes
Secure & Confidential
Required for First Visit

Patient Information

Health History

Vision, Hearing & Sensory

Respiratory

Cardiovascular

Skin Conditions

Infections

Pain & Discomfort - Describe Nature & Location

Other Medical Conditions

Fractures & Dislocations

Women's Health

Surgeries, Accidents & Special Notes

Consent to Treatment

Dear Client,

Depending on our assessment, we may be treating you while you are on your stomach, back, and/or side. We will work several musculoskeletal structures of which we will describe before each and every treatment session.

You will be covered by a sheet at all times, except for the areas that we will be working on. If needed, we may use pillows under your abdomen and/or legs in order to make you more comfortable and support your lower back.

Some risks of treatment are that some techniques may be deeper or more uncomfortable than others. We will adjust our pressure to your comfort level and will be checking with you during the treatment. It is possible you may feel side effects such as achiness the very next day, however if you follow the home-care suggestions we give you after each treatment, this is less likely to happen.

It is also possible that without treatment, your condition may get worse, stay the same, or get better. With treatment, your symptoms and healing process time may decrease. To compliment Swedish Massage Therapy, we may use hydrotherapy as well as a variety of assessment and treatment techniques. In addition, we may refer you to another type of therapist, depending on your progress with your massage treatments.

We will suggest a frequency of treatment specifically tailored to your needs, as well as a re-assessment time to evaluate your progress. It is your right to stop or modify your treatment at any time.

Missed Appointment Policy: For any Missed Massage Treatment, you will be charged in accordance with the RMTAO as follows: 2nd missed massage – 50% of the massage fee / 3rd missed massage – 100% of the massage fee. We allocated this time slot for you and your health and without proper notice, it is difficult to schedule another client who may need the treatment time.

Your consent here is provided and may be revoked at any time should you choose to do so.

Thank you and enjoy your treatment.

Massage Therapist Informed Consent

Nature of Treatment

Massage therapy involves the assessment and treatment of soft tissue and joints of the body. Treatment may consist of manual or adjunctive techniques to improve health and well-being. Techniques may include, but are not limited to: Swedish massage techniques, joint mobilizations, stretches, hydrotherapy, and various forms of therapeutic massage.

Potential Benefits

Benefits from massage therapy may include: relief from muscle tension and stiffness, reduced stress and anxiety, improved circulation, enhanced immune system function, improved sleep, relief from pain, increased range of motion, and general relaxation and wellness.

Possible Side Effects

In some cases, massage therapy treatment may cause temporary discomfort, muscle soreness, skin irritation or bruising. More serious complications, while rare, may include aggravation of a pre-existing condition or injury. If you experience any unusual symptoms or severe discomfort, please inform your therapist immediately.

Your Rights as a Patient

  • You have the right to ask questions about your treatment at any time
  • You have the right to refuse treatment or ask to stop treatment at any time
  • You have the right to request a different therapist
  • You have the right to be treated with respect and dignity
  • You have the right to privacy and confidentiality

Draping Policy

Professional draping will be provided at all times to ensure your comfort and modesty. Only the area being worked on will be undraped. You may request additional draping at any time during your session.

Confidential Consent

Privacy and Confidentiality

NovaCare Health and Wellness Centre is committed to protecting your privacy and maintaining the confidentiality of your personal health information in accordance with the Personal Health Information Protection Act (PHIPA) and applicable privacy legislation.

Collection and Use of Information

We collect personal health information for the following purposes:

  • To provide you with safe and effective massage therapy treatment
  • To maintain accurate health records
  • To communicate with other healthcare providers involved in your care (with your consent)
  • To process insurance claims on your behalf
  • To contact you regarding appointments and follow-up care
  • For administrative and billing purposes

Storage and Security

Your personal health information is stored securely in our clinic in both electronic and paper format. Access to your information is limited to authorized clinic staff who require it to perform their duties. We maintain physical, electronic, and procedural safeguards to protect your information.

Disclosure of Information

Your personal health information will not be disclosed to third parties without your written consent, except where required or permitted by law. Examples include:

  • When you have provided written authorization
  • When disclosure is required by law (e.g., court order, public health reporting)
  • In emergency situations to protect your health or safety
  • For insurance billing purposes (with your authorization)

Your Rights

  • You have the right to access your health records (subject to limited exceptions)
  • You have the right to request corrections to your health information
  • You have the right to request a listing of disclosures of your information
  • You have the right to withdraw consent for disclosure at any time
  • You have the right to file a complaint regarding privacy concerns

Retention of Records

Your health records will be retained for a minimum of 10 years from the date of your last treatment, or longer if required by law or professional standards.

Authorization & Direction to Disclose Personal Information

I hereby authorize and direct NovaCare Health and Wellness Centre and its massage therapists to disclose my personal health information as specified below.

Insurance and Billing Authorization

Healthcare Provider Communication

Family/Caregiver Authorization (Optional)

Important: This authorization remains in effect until revoked by me in writing. I understand that I may withdraw this authorization at any time by providing written notice to NovaCare Health and Wellness Centre.

Cancellation Policy

24-Hour Cancellation Notice Required

We understand that unplanned issues may come up and you will need to cancel an appointment. If this happens, we respectfully ask that you notify us at least 24 hours prior to your appointment time.

Our therapists want to be available to meet your needs as well as the needs for all of our patients. When a patient does not show up for a scheduled appointment, another patient loses the opportunity to be seen.

Cancellation Notice

We require a minimum of 24 hours notice for all appointment cancellations or changes. This allows us to offer your time slot to other patients who may be waiting for an appointment.

Missed Treatment Charges

If we are not provided with the appropriate notice, you will be responsible for a Missed Treatment charge of $50.00.

For Massage Therapy appointments, charges will be applied in accordance with the RMTAO as follows:

  • • 2nd missed massage – 50% of the massage fee
  • • 3rd missed massage – 100% of the massage fee

Billing for Missed Appointments

This charge will not be billed to any third-party payors. You will be billed directly, and it must be paid by you for you to continue to be treated under your claim.

Under certain circumstances, management may waive this fee.

Late Arrivals

If you arrive more than 15 minutes late for your appointment, we may need to reschedule your treatment to ensure we can provide quality care and maintain our schedule for other patients. You may be subject to the missed treatment charge.

How to Cancel or Reschedule

  • • Call us at (807) 623-4720
  • • Email us at the address provided in your confirmation
  • • Contact us through our online booking system (if applicable)

Please note that voicemails and emails left outside of business hours will be processed the next business day. It is your responsibility to ensure your cancellation is received within the 24-hour window.

Acknowledgment and Agreement

By checking the box below, I acknowledge that I have read, understood, and agree to comply with the cancellation policy of NovaCare Health and Wellness Centre. I understand that failure to provide adequate notice or to attend scheduled appointments may result in cancellation fees as outlined above.

Signature and Acknowledgment

By submitting this form, I certify that:

  • All information provided on this form is accurate and complete to the best of my knowledge
  • I have read and understand all consent forms and policies outlined in this document
  • I agree to inform my massage therapist of any changes to my health status
  • I consent to receive massage therapy treatment at NovaCare Health and Wellness Centre
  • I understand and agree to the cancellation policy

Please ensure all required fields are completed before submitting

After Submission: You will receive a confirmation email. Please bring a valid photo ID to your first appointment. If you have any questions about this form, please contact us at (807) 623-4720.