Patient Intake Form

Please complete this form in order to assist us in becoming familiar with your health history, and to ensure that the massage therapy services provided are best suited for you.

IMPORTANT NOTE: This form will NOT book you an appointment in our clinic. Please call 604 520 1830 to book your appointment BEFORE filling out this form.

  • Personal Information

  • Please book a time with us BEFORE completing this form.
  • Step 1

  • Please note: Massage therapy CANNOT be given if you are under 16 years old without the consent of a parent or legal guardian.
  • Please note: Massage therapy CANNOT be given at WCCMT if you are on an ICBC/WCB claim.
  • Step 2

    Please check any of the following if they apply to you:
  • If you checked yes to arthritis, please specify location(s):
  • Step 3

  • To what level are you currently satisfied with your?:

    Please check the level which you feel most accurately describes you (i.e. low, moderate, or high).
  • If you can't remember the exact day and month, a rough estimate is fine.
  • Please check all those that apply.
  • Consent & Release

  • Patient Signature

  • Instructor Signature

PCTIA Accredited "DESIGNATED B.C. PRIVATE TRAINING INSTITUTIONS BRANCH and Shield Design mark is a certification mark owned by the Government of British Columbia used under License" BC - Education Quality Assurance College of Massage Therapists of British Columbia
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