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Emergency Contact:

Health Coverage/Direct Billing Information (if applicable)

Primary Coverage Information:
Insured Member Spouse Child/Dependent
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.
Insured Member Spouse Child/Dependent

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.

Asthma
Croup
Chronic Pulmonary Disease (COPD)
Colds
Emphysema
Hay Fever
Influenza
Nose Bleeds
Pleurisy
Pneumonia
Rhinitis (Nasal Drip)
Sinus Congestion
Sinusitis
PMS
Pregnant
Menstrual Difficulties
Endometriosis
Prostate (male)
Sexually Transmitted Diseases
Arthritis OA/RA?
Cancer
Chronic Fatigue
Environmental Illness
HIV/AIDS
Allergies
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
Psoriasis
Eczema
Rash
Warts
Osteoporosis
Fibromyalgia
Back/Neck/Shoulder Pain
Foot/Arm/Hand problems
Bright's Disease
Cystitis
Edema
Gout
Incontinence
Kidney Stones
Nephritis
Obstruction to Ureters
Renal Abscess
Urethritis
Urinary Tract Infection
Diabetes Type 1 Type 2
Hypoglycemia
Hypothyroidism
Hyperthyroidism
Atherosclerosis
Anemia
High/Low Blood Pressure
Circulation problems
Heart Disease
Varicose Veins
Vision loss/problems
Hearing loss/problems
Loss of sensation
Nerve pain/damage
Numbness
Muscle Cramps - Where?
Joint Swelling - Where?
Tendonitis - Where?
Muscle Pain / Rheumatism - Where?
Sharp Burning Aching Fixed Other:
Sharp Burning Aching Fixed Other:
Sharp Burning Aching Fixed Other: