Back on Track Physiotherapy
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Home > Massage Therapy Intake Form

Massage Therapy Intake Form

Massage Therapy Intake Form

  • PAYMENT FOR SERVICES IS DUE AT THE TIME OF YOUR APPOINTMENT

  • (Please tell us how you heard of Back on Track.)
  • (Your email address will only be used by our clinic to communicate with you. It will not be sold or distributed.)
  • HEALTH HISTORY: Please indicate conditions you are experiencing, or have experienced.

  • Dear Client: Depending on our assessment, we may be treating you while you are on your stomach, back, and/or side. We will work several musculoskeletal structures of which we will describe before each and every treatment session. You will be covered by a sheet at all times, except for the areas that we will be working on. If needed, we may use pillows under your abdomen and/or legs in order to make you more comfortable and support your lower back. Some risks of treatment are that some techniques may be deeper or more uncomfortable than others. We will adjust our pressure to your comfort level and will be checking with you during the treatment. It is possible you may feel side effects such as achiness the very next day, however if you follow the home-care suggestions we give you after each treatment, this is less likely to happen. It is also possible that without treatment, your condition may get worse, stay the same, or get better. With treatment, your symptoms and healing process time may decrease. To compliment Swedish Massage Therapy, we may use hydrotherapy as well as a variety of assessment and treatment techniques. In addition, we may refer you to another type of therapist, depending on your progress with your massage treatments. We will suggest a frequency of treatment specifically tailored to your needs, as well as a re-assessment time to evaluate your progress. It is your right to stop or modify your treatment at any time. For any Missed Massage Treatment, you will be charged in accordance with the RMTAO as follows: 2nd missed massage – 50% of the massage fee / 3rd missed massage – 100 % of the massage fee. We allocated this time slot for you and your health and without proper notice, it is difficult to schedule another client who may need the treatment time. Your consent here is provided and may be revoked at any time should you choose to do so.

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