New Patient Intake

Basic contact information and an emergency contact, so your chart is complete before you arrive.

First name

Last name

Date of birth

Phone

Address

Emergency contact

Emergency contact phone

Family doctor (optional)

What brings you in?

How long has it been going on?

Under 2 weeks 2–6 weeks Months or longer

Anything we should know about? Tick what applies

Heart or blood pressure condition Diabetes Blood thinners or clotting disorder Recent surgery or fracture Pregnant or postpartum Skin condition or allergy to oils

Medications and past injuries or surgeries

How will this visit be paid?

Extended health ICBC claim Paying myself

Insurance provider

Policy / member number

ICBC claim number (if applicable)

Date of accident

We direct bill most major plans on covered visits, and bill ICBC directly under your claim. How direct billing works

Consent to treatment

Your therapist will explain the proposed treatment and answer your questions before starting. You stay draped throughout, only the area being treated is uncovered, and you may modify or withdraw consent at any point during the session — including asking for less pressure or stopping entirely.

I consent to assessment and massage therapy treatment, and I understand I can withdraw consent at any time. The health information I have given is accurate and complete to the best of my knowledge. I understand my records are confidential and kept as required by the College, and released only with my consent or where the law requires it.

Type your full name as signature

Date

Have your clinic's privacy officer review this consent wording against current CMTBC requirements before publishing.

Your details

Consent to treatment

Intake received

Paperwork done. See you at the clinic.