Confidential Patient Intake Form printable pdf download

Frank DeStefano, RMT

Stacy Ratcliff, RMT

Renata DeForest, RMT

Mandy Sanmiya, RMT

Registered Massage Therapy

Confidential Patient Intake Form

The information requested below will assist us in treating you safely. Feel free to ask any questions about the

information being requested. Please note that all information provided below will be kept confidential unless

allowed or required by law. Your written permission will be required to release any information outside this clinic.

Today’s Date (D/M/Y):

Name:

Date of Birth (D/M/Y):

Age:

Address:

City:

Postal Code:

Home Ph.

Cell Ph.

Business Ph.

Ext.

Email:

 Male

Business Ph.

Ext.

Weight:

Height:

May we send you emails about important office notifications including

 Female

appointment reminders and statements?

□ Yes □ No

Occupation:

Employer:

Medical Doctor’s Name:

Phone:

City:

Emergency Contact:

Relationship:

Phone:

Prior Massage Therapy?  Yes  No

Reason:  Relaxation  Medical

Did you receive treatment for this in the past?  Yes  No

What is your primary concern?

If Yes what type of treatment did you receive?

Have you had this condition in the past?  Yes  No

 Work related injury / accident (WSIB) Date of accident: ___________________ Claim Number: ____________

 Motor vehicle accident (MVA) Date of accident: ___________________

How did you hear about our office?

 Family doctor

 Family / Friend

 Yellow Pages

 Internet

 Other _______________

 I understand that massage therapy involves the manipulation of soft tissues and joints of the body in order to develop,

maintain, rehabilitate, improve physical function, or relieve pain.

 I understand that during a massage treatment the massage therapist will, to the best of his/her ability, undrape only

the area to be massaged, providing the draping, comfort, warmth, security, and privacy as requested.

 I consent to a massage and I understand that I can change or terminate my treatment at any time.

 I also understand that I am responsible for any charges incurred in the course of my treatment.

 I understand that 24 hour notice is required to reschedule all future appointments, or full charges will apply.

Signature:

Date:

Please note this is a multi-disciplinary clinic. This is to confirm that I give my consent to allow the other massage

therapists at Central Health Care to access the information in my file and administer treatment should it be required.

Patient Initials: ___________

CHC Massage Intake 1 of 2

806 Gordon St. Guelph ON N1G1Y7

Confidential Patient Intake Form

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