RMT CLIENT INTAKE & CONSENT FORM

RMT Client Intake & Consent Form

Please fill out the following form so that we can connect you with the best possible service. 
Gender:
Preferred Level or Pressure

Patient Conditions

If you are currently experiencing a listed symptom or have experienced it in the past, please check the box next to the symptom.

Respiratory
Skin
Cardiovascular Head & Neck
Infectious Conditions
Women
Soft Tissue/Joint Dysfunction
Family History
Miscellaneous
Neurological
I certify that the above information is complete and accurate to the best of my knowledge. I agree to notify LHN or my LHN RMT of any changes to my health or personal information.

Patient Consent Form


It is strongly advised that you read and understand the following policies. If you have any questions, please ask.
  • A client health history form is a legal requirement mandated by the College of Massage Therapists of Ontario (CMTO) to help treat you safely and effectively.
  • A client health history form is required prior to your first treatment, every year, and after an absence of one year from your last treatment.
  • All information discussed and recorded is completely confidential.
  • Your written authorization is required for the release of any personal information pertaining to your file.
  • Massage therapy is defined as the assessment and treatment of the soft tissue and joints of the body. Therefore, every Registered Massage Therapist (RMT) may employ a variety of different techniques during a massage therapy treatment.
  • A Registered Massage Therapist is unable to “diagnose” any form of illness, disease or injury.
  • An “appointment” should not be interpreted as the length of the “treatment”. An “appointment” may include a client intake form discussion, assessment, treatment and assignment of remedial exercises.
  • The client may terminate the treatment at any point, at their discretion and without reason. The therapist can also terminate the appointment if it is thought to be unsafe or unsuitable.
  • In the case of late arrivals, it should be understood that only the time remaining for your scheduled appointment will be allotted, unless additional time is available.
  • Fees for appointments vary for each RMT providing Massage Therapy services to your home.
  • Payments can be made by debit or credit card through www.lateralhealthnetwork.com/payinvoice, immediately following receipt of invoice. A receipt will be followed by your payment.
  • Please allow 24-hours’ notice if you are unable to make your appointment. Missed appointments will be given a free “missed appointment” and will not be charged. Further missed appointments without 24 hours’ notice may be issued a full charge of the scheduled time, except in the event of illness or unforeseeable circumstances.

Your form has been safely and securely submitted to LHN!