Patient Intake Form

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 250-381-9800 ext 221 to book your appointment BEFORE filling out this form.
  • 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 - the following fields are required to be completed

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

    Please check the level which you feel most accurately describes you (5 represents total satisfaction, 1 represents little or no satisfaction)
  • Please check all those that apply and specify in the box below
  • Consent & Release

    Our supervisory staff are all experienced Registered Massage Therapists and will do their best to see that you receive treatment best suited to your condition or need. Our clinic makes every effort to ensure that your treatment is safe and effective. If you wish to discuss any aspect of your treatment with a Clinic Supervisor please inform the receptionist or your Massage Therapy Student Intern.
  • Patient Signature

  • DD slash MM slash YYYY

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