Patient Intake Form

Patient Intake Form

All new patients to the Public Intern Clinic must complete a patient intake form which assists us in becoming familiar with your health history and ensures that the massage therapy services provided are best suited for you. Patients can either complete a printed form when they arrive at the clinic for their appointment or complete the online form in advance.

If you choose to complete the online form, you must have already booked your appointment which can be done either online or by phone at 604-520-1830

  • Personal Information

  • DD slash MM slash YYYY
  • Please book a time with us BEFORE completing this form.
    :
  • DD slash MM slash YYYY
  • 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.
    DD slash MM slash YYYY
  • Please check all those that apply.
  • Consent & Release

  • Patient Signature

  • DD slash MM slash YYYY
  • Instructor Signature

  • MM slash DD slash YYYY

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