PDF Forms All new form First Name: Last Name: Address: Date of Birth: Gender: Male Female Telephone: Home Cell Do we have permission to send appointment reminders, emails, and clinic updates? Yes No E-mail Address: Emergency Contact: Name Telephone: Relationship: Health Coverage/Direct Billing Information (if applicable) Primary Coverage Information: Primary Insurance Company: Name of Insured: Patient's Date of Birth: Insurer's Date of Birth: Relationship: Insured Member Spouse Child/Dependent Group/Plan Number: ID Number: Secondary Coverage Information (if applicable):NOTE: NOT ALL INSURANCE COMPANIES SUPPORT SECONDARY DIRECT BILLING - IN THESE INSTANCES, SECONDARY COVERAGE MUST BE SUBMITTED MANUALLY BY CLIENT. Insurance Company: Name of Insured: Relationship: Insured Member Spouse Child/Dependent Group/Plan Number: ID Number: No Show/Late Cancellation Policy: As a courtesy to other patients and the therapists, we ask that you give us a 24 hour notice if you cannot make it to your scheduled appointment. Our policy is to charge for missed appointments at the rate of 50 percent of the scheduled visit, billed directly to you, and payable prior to your next visit. DISCLAIMER Body Therapy Wellness Centre does not render any services or provide any care or treatment. Body Therapy Wellness Centre is an office location through which independent practitioners conduct their business. The individual practitioner that performs the services is independent from Body Therapy Wellness Centre and responsible for the services rendered. Additionally, not all of the practitioners at Body Therapy Wellness Centre are licensed medical doctors; some services available at Body Therapy Wellness Centre are complementary to and not a substitution for treatment by a licensed medical doctor. As such, by signing below, you indicate that you understand the No Show/Late Cancellation Policy, and the above Disclaimer. Please be aware that all accounts not paid by the insurance company for which direct billing is possible is the responsibility of the client. We are not able to direct bill for all treatments. Please check with your insurance company to find out which services are direct billable. Signature: Date: Please list any health concerns that you may have: How long have you had these concerns? Occupation: Please list any allergies/sensitivities: Please check/circle any issues that apply to you: Respiratory Asthma Croup Chronic Pulmonary Disease (COPD) Colds Emphysema Hay Fever Influenza Nose Bleeds Pleurisy Pneumonia Rhinitis (Nasal Drip) Sinus Congestion Sinusitis Reproductive PMS Pregnant Menstrual Difficulties Endometriosis Prostate (male) Sexually Transmitted Diseases Immune & Lymphatic Arthritis OA/RA? Cancer Chronic Fatigue Environmental Illness HIV/AIDS Allergies Digestive Crohn's/Celiac Disease Cirrhosis Colitis Constipation Diarrhea Digestive Problems Diverticulitis Duodenal Ulcer Food Poisoning Gall Stones Gastritis Hepatitis Hiatus Hernia Hypoglycemia Indigestion Inflammatory Bowel Disease (IBS) Jaundice Parasite Infection Peptic Ulcer Integumentary (Skin) Psoriasis Eczema Rash Warts Musculoskeletal Osteoporosis Fibromyalgia Back/Neck/Shoulder Pain Foot/Arm/Hand problems Urinary Bright's Disease Cystitis Edema Gout Incontinence Kidney Stones Nephritis Obstruction to Ureters Renal Abscess Urethritis Urinary Tract Infection Endocrine Diabetes Type 1 Type 2 Hypoglycemia Hypothyroidism Hyperthyroidism Cardiovascular Atherosclerosis Anemia High/Low Blood Pressure Circulation problems Heart Disease Varicose Veins Nervous Vision loss/problems Hearing loss/problems Loss of sensation Nerve pain/damage Numbness Are you undergoing other therapies? For massage clients - Is this your first massage? List past surgeries: List past injuries/accidents/serious illnesses with dates: Are you taking medications? Include any vitamins, dietary supplements, over the counter items: Is there anything else about your health that you would like to discuss? If yes, please explain: Please mark problem areas on diagram: Musculoskeletal Muscle Cramps - Where? Joint Swelling - Where? Tendonitis - Where? Muscle Pain / Rheumatism - Where? Describe Pain and Location: (From 1 - 10 : 10 being the worst please grade the level of pain) Sharp Burning Aching Fixed Other: Sharp Burning Aching Fixed Other: Sharp Burning Aching Fixed Other: