Saskatoon Massage Therapy Intake Form

First Name

Last Name

Perferred Name

Pronoun

What is your Date of Birth

Cellphone

City/Town

Postal Code

Address

Emergency Contact Phone # (name is optional)

What are your regular activities that increase muscle tension? (Job, School..etc)

What is your primary concern?

What is your occupation? Does it cause stress or tension?

How did you find out about StoonRMT?

I consent to allow my therapist/receptionist to submit Direct Billing on my behalf

If you have, you can add your direct billing information below and it will attach directly to your file for future reference.

Date of injury:

SGI/WCB Claim Number:

Health Card #: (Only for WCB/SGI claims)

I want to subscribe to the newsletter.

Myofascial
Release in Saskatoon