Intake Form

Emergency Contact:

Health Coverage/Direct Billing Information (if applicable)

Primary Coverage Information:

Secondary Coverage Information (if applicable):NOTE: NOT ALL INSURANCE COMPANIES SUPPORT SECONDARY DIRECT BILLING - IN THESE INSTANCES, SECONDARY COVERAGE MUST BE SUBMITTED MANUALLY BY CLIENT.

No Show/Late Cancellation Policy:
As a courtesy to other patients and the therapists, we ask that you give us a 24 hour notice if you cannot make it to your scheduled appointment. Our policy is to charge for missed appointments at the rate of 50 percent of the scheduled visit, billed directly to you, and payable prior to your next visit.

DISCLAIMER

Body Therapy Wellness Centre does not render any services or provide any care or treatment. Body Therapy Wellness Centre is an office location through which independent practitioners conduct their business. The individual practitioner that performs the services is independent from Body Therapy Wellness Centre and responsible for the services rendered. Additionally, not all of the practitioners at Body Therapy Wellness Centre are licensed medical doctors; some services available at Body Therapy Wellness Centre are complementary to and not a substitution for treatment by a licensed medical doctor. As such, by signing below, you indicate that you understand the No Show/Late Cancellation Policy, and the above Disclaimer.

Please be aware that all accounts not paid by the insurance company for which direct billing is possible is the responsibility of the client. We are not able to direct bill for all treatments. Please check with your insurance company to find out which services are direct billable.