Health Intake Form 2026

First Name

Last Name

Date of Birth

Phone

Address

Location

Downtown North York

Occupation

Emergency Contact information (Name, Phone Number, Relationship to Patient)

Family Doctor Name and Address

Billing & Insurance Information

Billing & Insurance Information

(If choosing direct billing, I consent to my healthcare provider collecting, using, and disclosing personalized information for the purpose of processing my insurance claims, and I assign payment of eligible benefits directly to the clinic.)

Do you have extended health care insurance?
Yes, I authorize direct billing to my insurance provider. Yes, I will submit my own claims. No, I do not have insurance coverage.

Please note that we cannot guarantee the result of direct billing. You will need to pay the remaining that are not covered by the insurance.

How many insurance providers do you work with?
One, I am the plan member. One, I am under family cover. More than one.

Please note that we cannot help direct billing for this situation. You may claim by yourself with the treatment invoice :)

Please share plan member`s name, date of birth and your relationship.

Other Insurance Provider

Primary Insurance Contract number or Policy number

Primary Insurance Member ID or Certificate Number

What is the primary purpose of your visit today?
(Select all that apply)
Relaxation and stress relief Pain management (e.g. back, neck, shoulder, or joint pain) Muscle tension release or posture correction Injury or sports recovery Rehabilitation or mobility improvement Holistic balance/body alignment (e.g. osteopathic or acupuncture care) Digestive, sleep, or hormonal balance support Headache, migraine, or TMJ treatment Other (please discuss with your therapist)

Please select any conditions you are experiencing (past and present):

Blood
Anaemia Haemophilia Leukemia Hepatitis

Please list any other concerns/ allergies/ drug reactions/ risk factors/ long term treatments that may be relevant.

Cancellation Policy
Cancellation Policy
You can cancel or reschedule it online or on the phone within 24 hrs prior to your appointment otherwise a cancellation fee (60% of your sessional price) will be charged.

Health Intake and Consent Form
Health Intake and Consent Form
Collection and Use of Personal Health Information
Osteo Tuina Clinic collects, uses, and discloses personal health information to provide treatment and related services.
Information may include birth date, contact information, health history, health status, substitute decision-maker, health number, insurance, and details of care received.
Practitioners may collect, use, or disclose information without consent as permitted by law.
Purpose of Information Use
To provide massage therapy, acupuncture, or osteopathy services.
To obtain payment for services.
To assist with insurance claims.
To seek advice on treatment options.
To provide or arrange emergency health care.
To fulfill legal obligations.
Initial Consultation and Treatment
Certified therapists review the Health History Form during the first visit to ensure tailored treatment plans.
Customers must update this form annually.
Health Records and Consent
Certified True Copies of receipts are available for $5 per duplicate.
Copies of treatment records cost $2 per page plus a $50 administrative fee. Discuss medical reports directly with therapists.
Appointment Policies
Customers are responsible for their reserved time slots. Late arrivals will not extend treatment time or reduce fees.
Handling of Personal Information
Personal information is primarily collected to provide treatment, ensure quality, comply with regulations, and respond to inquiries.
Information may be shared with regulatory bodies or as required by law, adhering to privacy obligations.
Records are kept for ten years and securely destroyed thereafter.
Viewing Your Information
Customers have the right to access their personal information, with some exceptions, for a nominal fee.
Requests for corrections to inaccuracies are allowed.
Acknowledgment of Medical Conditions
Therapists must be fully informed of the customer's medical history for safe and effective treatment.
Customers are responsible for providing accurate information and updating any health status either insurance status changes.

By engaging with our services, you acknowledge and consent to our clinic policies and the handling of your personal information as described, ensuring a safe, respectful, and confidential treatment environment.

I give consent to cancellation and liability information