I certify that the above medical information is correct to my knowledge.

I authorize the clinic and its associated health professionals to collect my personal and medical information as documented above. In addition, I authorize the clinic and its associated health professionals to communicate with my family doctor and/or referring doctor as deemed necessary for my beneficial treatment. I also understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission.

Please arrive 5 minutes prior to your appointment to allow time for any required paperwork as well as answer intake questions your therapist may have. Arriving after your appointment time may result in lost time from your treatment as we are unable to exceed that reserved time without affecting the next client session. Full service fees will be charged even when sessions are shortened due to late arrival.

Please arrive 5 minutes prior to your appointment to allow time for any required paperwork as well as answer intake questions your therapist may have. Arriving after your appointment time may result in lost time from your treatment as we are unable to exceed that reserved time without affecting the next client session. Full service fees will be charged even when sessions are shortened due to late arrival.

Our manual therapies are for relaxation & therapeutic purposes only. There is absolutely no sexual component to treatment whatsoever. Any insinuation, joke, gesture, conversations or request will result in immediate termination of the session and a refusal of any and all future services. Full service fees will be charged regardless the length of the session.

I understand that services are provided for stress reduction, relaxation, relief from muscular tension and improvement of circulation & energy flow. If I experience pain or discomfort during my session, I will immediately inform my therapist so that pressure/strokes or any other aspect of the treatment can be adjusted to to my level of comfort/satisfaction. While rare, some clients may experience short-term aggravation of symptoms or bruising as a result of the treatment given. I understand that the services offered are not a substitute for medical care. I affirm that I have notified the therapist of all medical conditions and injuries. I agree to inform the therapist of any changes in my health. I understand that there shall be no liability on the therapist’s part should I forget to do so. By signing this release, I hereby waive and release the therapist and Urban Massage & Wellness Inc. from any and all liability, past, present & future relating to manual osteopathy & massage therapies including (but not limited to) myofascial cupping, hot stone treatments, Rapid NFR & fascial stretch therapy.

I have competed the intake form for the above mentioned minor and informed the therapist of any and all relevant medical history and concerns. I understand the scope of manual therapy and that it is not meant to diagnose, treat or cure any conditions and is not a replacement for standard medical care. I give permission for my minor child to receive treatment(s) at Urban Massage & Wellness and agree to all of the above terms.

Payment is due at time of treatment. In the event my claim(s) are declined or come back as pending by the insurer/plan administrator, I understand that I remain responsible for the payment to the provider for any services rendered and/or supplies provided.

I understand that the therapist is an Independent Contractor and I consent to them contacting me directly, by the methods for which I have provided my contact information, in regards to matters related to my appointments, including booking, cancellations, or rescheduling, and my treatment plan, including follow-ups and additional support.