Massage Therapy, Chiropractic & Acupuncture
Carolyn Anthony, RMT, Tammy Townsend, RMT & Amy Breese, RMT
235 Starwood Dr. Unit 3
Guelph, ON, N1E 7M5
(519) 763-8855
Fax (519) 763-8388
Please be advised the following information is required to ensure the most effective care and treatment plan
can be created for you. The information on this form will be held in the strictest of confidence and used
only for treatment purposes. In accordance with provincial privacy legislation your consent must be
obtained regarding the collection, use and disclosure of personal information (including health
information). The purpose for collecting, using and disclosing this information is set out in the “Consent for
Assessment and Treatment” form and in the CMTO Privacy Code (8 pg. Doc. Available for viewing upon
request).
Name: _________________________________________ Email: _________________________________
Address: ____________________________________ City: ______________ Postal Code: ____________
Home Phone: _________________ Cell Phone/Provider (i.e. Rogers etc.):__________________________
Appointment Reminders: (Please circle which you prefer) Home Phone / Cell Phone / Text / Email
Date of Birth (DD/MM/YY): ___________________
Occupation: _____________________ Employer: ______________________ Phone: _________________
How did you hear of the clinic? ____________________________________________________________
Name and Address of Primary Care Physician: ________________________________________________
Did a health care practitioner refer you for massage therapy?
Yes
No
If yes, please provide their name. ___________________________________________________________
Please list your current involvement with other health care practitioners. ____________________________
______________________________________________________________________________________
Please list the current medications you are taking and the conditions they are treating. _________________
______________________________________________________________________________________
Please list the timing and nature of any injuries or accidents. _____________________________________
______________________________________________________________________________________
Please list the timing and nature of any surgical procedures. ______________________________________
______________________________________________________________________________________
Do you have any internal pins, wires, artificial joints or special equipment?
Yes
No
If yes, what is it and where is it in your body? _________________________________________________
Overall, how is your general health? ________________________________________________________
What is your primary complaint? ___________________________________________________________
What is the location and nature of your soft tissue and / or joint discomfort?
______________________________________________________________________________________
______________________________________________________________________________________
Do you have any loss of vision?
Yes
No
If yes, to what degree?
______________________________________________________________________________________
Do you have any loss of hearing? Yes
No
If yes, to what degree?
______________________________________________________________________________________
Do you have any loss of sensation? Yes
No
If yes, to what degree?
Do you have any cardiovascular insufficiencies including (please check any that apply):
 High blood pressure
 Heart disease
 Low blood pressure
 Phlebitis
 Pacemaker or similar device
 Chronic congestive heart failure
 History of myocardial infarction
 History of cerebrovascular accident
 Other, please describe_________________________________________________________________
Do you have any respiratory insufficiencies including (please check any that apply):
 Chronic cough
 Bronchitis
 Shortness of breath
 Asthma
 Emphysema
 Other, please describe_________________________________________________________________
Do you have any allergies or hypersensitivities?
 Yes
 No
If yes, what are they and is the response anaphylaxis or skin irritation?
______________________________________________________________________________________
______________________________________________________________________________________
Do you have diabetes?
Do you have arthritis?
Do you have cancer?
Do you have epilepsy?




Yes
Yes
Yes
Yes




No
No
No
No
Do you have any infectious conditions such as tuberculosis, AIDS/HIV, hepatitis, influenza, SARS?
 Yes
 No
If yes, what?
______________________________________________________________________________________
Do you have any skin conditions?
 Yes
 No If yes, what is it and is it infectious?
______________________________________________________________________________________
Do you have any digestive conditions?
 Yes
 No If yes, what?
______________________________________________________________________________________
Do you have any blood conditions?
 Yes
 No If yes, what?
______________________________________________________________________________________
Do you have any other medical conditions?
 Yes
 No If yes, what
______________________________________________________________________________________
Do you have any family history of a disease or condition?
 Yes
 No If yes, what
______________________________________________________________________________________
If you are female, please answer the following questions:
Are you pregnant?
 Yes
 No
If yes, how far along are you? _____________________________________________________________
Do you have any gynecological conditions?
 Yes
 No If yes, what
______________________________________________________________________________________
______________________________________________________________________________________
The information I’ve given is correct and I will inform the therapist of any changes.
_____________________________________
Name of Client or Guardian
___________________________________
Date
Massage Therapy, Chiropractic & Acupuncture
Carolyn Anthony, RMT & Tammy Townsend, RMT & Amy Breese,RMT
235 Starwood Dr. Unit 3
Guelph, ON, N1E 7M5
(519) 763-8855 Fax (519) 763-8388
FEE SCHEDULE & OFFICE POLICY
It is the policy of this clinic that payment is required at the time that services are
rendered. No credit or accumulation of fees is permitted. Cash, Cheque, Debit or
Credit Card is accepted.
IMPORTANT
Reminder calls/emails are a courtesy provided by the clinic. However,
remembering your appointment is your responsibility.
Twenty four (24) hours notice of cancellation is required. Without 24 hours
prior notification, you will be billed a fee of $40.00. All NSF cheques will be
charged a $30.00 fee.
Massage Therapy Fees including HST
90 minutes
60 minutes
45 minutes
30 minutes
$120.00
$82.00
$65.00
$50.00
Hot Stone Massage
60 minute
$105.00
45 minute back, neck & face $80.00
Extended Health Coverage
Many extended health care insurance plans cover Massage Therapy. Check with
your employer for details. Fees to be recovered from extended health insurance
plans are the patient’s responsibility. If other financial arrangements are required,
please discuss them with your individual therapist prior to your treatment.
I clearly understand and agree that ALL services rendered to me are charged
directly to me and that I am personally responsible for payment.
I have read and acknowledged all the above information.
SIGNATURE: _____________________________ DATE: _________________
If patient is a minor, signature of Parent/Guardian.
Massage Therapy, Chiropractic & Acupuncture
Carolyn Anthony, RMT & Tammy Townsend, RMT & Amy Breese, RMT
235 Starwood Dr. Unit 3
Guelph, ON, N1E 7M5
(519) 763-8855 Fax (519) 763-8388
INFORMATION CONSENT & ACCURACY APPROVAL FORM
I am aware that this office is keeping personal information as outlined in the
PRIVACY POLICY for the reasons disclosed. I am aware that the members of
the staff of this office may access this information. I give my consent for this
information to be collected and disclosed as outlined to me.
yes___
no_____
My file may be used for Quality Audit purposes.
yes___
no_____
You may consult another health practitioner about my case.
DATE: __________________ SIGNATURE: ____________________________
If Parent or Guardian is signing:
Signature: _________________________________________
NAME (Please Print):________________________________
Relationship: _______________________________________
PERSONAL INFORMATION ACCURACY
I have reviewed my information with the office and accept that it is substantially
accurate.
DATE: ______________ SIGNATURE:________________________________
DATE: ______________ SIGNATURE:________________________________
DATE: ______________ SIGNATURE:________________________________
DATE: ______________ SIGNATURE:________________________________
DATE: ______________ SIGNATURE:________________________________
DATE: ______________ SIGNATURE:________________________________
Massage Therapy, Chiropractic & Acupuncture
Carolyn Anthony, RMT, Tammy Townsend, RMT & Amy Breese, RMT
235 Starwood Dr. Unit 3
Guelph, ON, N1E 7M5
(519) 763-8855 Fax (519) 763-8388
Consent for Assessment and Treatment
I understand the purpose of an assessment is to determine if massage therapy is indicated
for me. The nature and purpose of the assessment will be discussed and I will be given
the opportunity to ask questions.
I will be informed of the proposed treatment plan and will be given the opportunity to ask
questions. Prior to the treatment I will be informed of the areas which will be treated, the
proper positioning, and draping on the table.
I understand I have the ability to refuse, alter or rescind consent at any time throughout
the treatment.
I have honestly answered the health history questions, and understand the importance of
informing you of any change. I understand the nature and purpose of the Massage
Therapy treatment and therefore give my consent to start treatment.
__________________________________
________________________
Signature of Client
Date
__________________________________
________________________
Signature of Guardian
Date