Name: Kaizen Health Group
Brand: Kaizen Health Group
Rating: 4.8 (1925 reviews)

Intake Form

eClaims Direct Billing Forms - All Locations

Complete this form if your insurance provider is one of the following;

BPA – Benefit Plan Administrators
Canada Life
Canadian Construction Workers Union
Chambers of Commerce Group Insurance
CINUP
ClaimSecure
Coughlin & Associates Ltd.
Cowan
D.A. Townley
Desjardins Insurance
First Canadian
GMS Carrier 49 or GMS Carrier 50
GroupHEALTH
GroupSource
Industrial Alliance
Johnson Inc.
Johnston Group Inc.
La Capitale Insurance and Financial Services,
LiUNA Local 183 or LiUNA Local 506
Manion
Manulife Financial, Maximum Benefit
People Corporation
RWAM Insurance Administrators
Sun Life Financial
TELUS AdjudiCare
Union Benefits
UV Insurance.

Sun Life Direct Billing Form - All Locations

Important: This form must be completed by the insured member. If you are a dependent on the policy you must have the policy holder complete and sign this form before we are able to direct bill on your behalf. This form cannot be completed by the plan members dependents.

Name of Primary Care Physician

Address of primary care physician

Have you received massage therapy before?

Are you currently receiving treatment from another health care professional?

Overall, how is your general health?

What is the primary reason you are seeking massage therapy? Indicate the location or any tissue or joint discomfort:

Have you had this condition in the past?

Yes No

Have you experienced loss of sensation? If so, where?

Are there any areas you would like NOT massaged?

Please indicate conditions you are experiencing or have experienced:

Cardiovascular

Is there a family history of any of the above?

Yes No Unknown

Respiratory

Is there a family history of any of the above?

Yes No Unknown

Infections

Head/Neck

History of headaches/migraines Vision loss/Vision issues Hearing Loss

Women | Pregnant, due:

Women | Gynaecological conditions Specify:

Past Accidents/Fractures/Surgeries

Do you have any other medical conditions? (e.g. digestive conditions, haemophilia, osteoporosis, mental illness

Yes No

Do you have any internal pins, wires, artificial joints or special equipment?

Yes No

Current Medications:

Current Medications: Current Conditions:

Disclaimer

I understand that massage therapy involves the manipulation of soft tissues and joints of the body in order to develop, maintain, rehabilitate, improve physical function, or relieve pain
. • I understand that Kaizen Health Group will not be held liable for any injury or condition that arises from my treatment, despite completion of this form.
• I acknowledge that this information is confidential and intended for review only by staff members of Kaizen Health Group
• I recognize that each session includes times for assessment, treatment, homecare instructions, and time to undress/redress.
• I consent to my treatment and I understand that I can change or terminate my treatment at any time, but that I will be liable to pay, at minimum, the cost of the originally booked session.
• I understand that I am responsible for any charges incurred in the course of my treatment.
• I also understand that any illicit or sexually suggestive remarks of advances made by myself will result in immediate termination of the session, and I will be liable for full payment of the appointment.
• I am aware that 24 hours notice is required to reschedule or change all future appointments or a no show/late cancellation fee of $30 will be charged to me.

CONSENT

I hereby request and consent to the performance of massage therapy, reflexology treatment, and other soft tissue procedures, including various forms of massage therapy, hydrotherapy, range of motion and orthopedic testing by the Therapist. I understand that I will have the opportunity to discuss my treatment with my Therapist. I also understand that results are not guaranteed. I further understand and am informed that in the practice of massage therapy, as in all health care, there are some slight risks to the treatment, including but not limited to: muscle tenderness, stiffness, and sometimes bruising. I do not expect the Therapist to be able to anticipate all the risks and complications associated with my treatment. I wish to rely on the Therapist to exercise judgement during the course of my treatment(s) to apply the methods which he/she feels at the time, based on the facts known, and are in my best interest. By signing below, I am signifying my agreement to massage therapy and I intend this consent to apply to and cover the entire course of my treatment(s) with Kaizen Health Group.

I have completed this form to the best of my knowledge:

Intake Form

eClaims Direct Billing Forms - All Locations

Sun Life Direct Billing Form - All Locations

Intake Form

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