Body Connections Fitness & Massage Therapy
Health History
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Email *
First and last name:
Mailing address including postal code *
Health card number: *
Date of birth, including year *
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Phone number: *
Insurance companies call the clinic to verify claims. Please provide the name of the Insurance Company you are submitting receipts to:
Insurance Policy Number
Occupation:
Referred by: *
Reason for treatment/area of body affected
Describe your pain/discomfort if applicable
Past or recent surgeries, injuries:
Family Doctors name and phone number:
List other care providers : ex-Specialists, chiropractor, physiotherapist etc:
List current medication:
Are you currently on blood thinners?
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Do you have surgical implants in your body?
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Have you had an Xray, MRI, ultrasound, or Cat scan for your current condition? Please list and describe results: Please bring in copies of any reports to your appointment.
Do you have a history of Covid -19?
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If you answered yes to having `Covid-19 in the past, please check the boxes that apply
Date of Covid-19 infection if applicable
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Do you suffer from any of the following? *
Required
Check the boxes that apply to your current or past health: *
Required
Check the boxes that apply; *
Required
Current allergies:
Are you currently pregnant?
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Do you smoke?
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Do you exercise?
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I understand that I must inform my therapist of changes in my health and medication before each treatment. Some medications may increase the likelihood of bruising and may affect the type of treatment provided. *
Required
I understand that my therapist is not a physician and does not diagnose medical conditions. However, I understand assessment is utilized by my therapist to devise and implement an appropriate treatment plan in their scope of practice. I consent to such an assessment and treatment. *
Are you experiencing any of the following? *
Required
I authorize Body Connections Fitness and Massage Therapy to release or obtain any information pertaining to my condition and or treatment to or from my other caregivers or third party payers. *
I understand that some treatments provided may result in local discomfort during the treatment, post treatment soreness, redness and sometimes bruising. This has been explained to me by my therapist. *
To the best of my knowledge, the above information is current and correct. I give my consent for massage therapy assessment and treatment.  *
Informed Consent to Massage Therapy Treatment:

I understand that the massage therapist is providing massage therapy within their scope of practice as defined by the Massage Therapist Association of Saskatchewan, Inc. I hereby consent for my therapist to treat me with massage therapy for the above noted purposes including such assessments, examinations and techniques which may be recommended by my therapist. 

I  understand that the therapist is not a physician and does not diagnose illness or disease or any other physical or mental disorder. I clearly understand that massage therapy is not a substitute for a medical examination. It is recommended that I attend my personal physician for any ailments that i may be experiencing. I acknowledge that no assurance or guarantee has been provided to me as to the results of the treatment.I acknowledge there can be risks and those risks have been explained to me and I assume those risks. 

I acknowledge and understand the therapist must be fully aware of my existing medical conditions. I have completed my medical history form as provided by my therapist and disclosed to the therapist all of those medical conditions affecting me. It is my responsibility to keep the massage therapist updated on my medical history. The information I have provided is true and complete to the best of my knowledge. 

I authorize my therapist to obtain information pertaining to my condition(s) and / or treatment to/from my other caregivers or third party payers. 

I have read the above noted consent and I have had the opportunity to question the contents and my therapy.By signing this form, I confirm my consent to treatment and intend this this consent to cover the treatment discussed with me and such additional treatment as proposed by my therapist form time to time, to deal with my physical condition and for which I have sought treatment. I understand that at any time I may withdraw my consent and treatment will be stopped.
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Do you give permission for Body Connections Fitness and Massage Therapy to contact you via email, phone call or text message? Contacting you is required for appointment booking, reminders, updates and receiving receipts. Services cannot be conducted if you check no. *
I understand that in case of a medical emergency, I am to contact my physician, 911, or seek medical care at a hospital. I understand my therapist is not on call and cannot answer clinical questions outside my appointment time. I understand text messages and emails are utilized for appointment bookings and not clinical discussion. *
Please include anything else you wish to share about your medical history:
I understand that appointment changes and cancellations require 24 hours notice. Payment is required without sufficient notice. Monday appointments are to be cancelled the Friday prior before 430pm. Once payment has been submitted, refunds are not provided. I agree to pay the full cost of the treatment if the cancellation policy is not adhered to. I understand this policy and agree to it. *
Date today: *
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Please type your full name below and we will consider it your virtual signature. *
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