First Visit

For the initial treatment, filling out this form along with assessment and review of your health history will count towards your treatment time. We recommend you fill out your forms ahead of time so it will not cut into your treatment time. Questions will be asked in regards to this form so that you receive a treatment that meets your needs. This form must be updated annually or if there is any change in address, phone number or in your health. It is your responsibility to keep your RMT updated.

Illness

If you have a fever, a cough related to flu, cold symptoms or anything that may be contagious, please call and reschedule your appointment. Massage is contraindicated for all the above conditions and may exacerbates symptoms.

No Scent Policy

Please be courteous and refrain from using large amounts of perfume or other scents.

Zero Tolerance Policy

We have zero tolerance for any type of verbal abuse, sexual harassment, bullying, inappropriate comments and behaviour.

Personal Hygiene

Personal hygiene is the principle of maintaining cleanliness and grooming of external body.
Please be respectful to your therapist by:

• maintaining personal cleanliness
• practicing good oral hygiene
• using deodorant to minimize body odour
• washing hands thoroughly
  

Risks

As with all healthcare, there are some risks that are associated with massage therapy. Although rare, they include but are not limited to, bruising, muscle sprains/strains/spasms, muscle soreness, skin irritation, miscarriages,induced labour, and short term aggravation symptoms. Epione is not liable or responsible for any adverse effects.

Cancellation/Rescheduling Policy and Missed appointments

If you do not cancel your appointment within the 72 hour time frame or miss your appointment, a late cancellation fee (75% of scheduled service) will be charged without notice. This is effective immediately if booked within the 72hr time frame. Fee must be paid before rescheduling. Please see below.

Missed appointments are 100% of treatment fee

If you do not show up within 15 minutes of your scheduled appointment time and do not notify us (call or email),your time slot will automatically be forfeited. Fees for late cancellation/rescheduling:

• 30 mins – $53.10
• 45 mins – $65.05
• 60 mins – $78.32
• 75 mins – $98.23
• 90 mins – $117.48

*All fees are subject to change and HST

Lateness Policy

If you are late for your appointment, the treatment will still end at the designated time with no change in fee.
If you do not show up within 15 minutes of your scheduled appointment time and do not notify us (call or email), your time slot will automatically be forfeited.

Agreement to Terms

I agree and consent to assessment and treatment. I have read the above information and have stated all my previous and current medical conditions. I understand and consent that my medical information may be shared by the various care providers involved in my care and treatment. I understand that all client information is confidential and written authorization must be obtained prior to the release of information. I take it upon myself to update the massage therapist regarding any changes to my health history. I understand that all massage treatments will be discussed and planned with the massage therapist and require my informed consent. I understand that there are risks to massage therapy as listed above. I understand that there is a 72 hour cancellation/rescheduling policy and agree to pay the missed appointment fee if I do not cancel or reschedule within the 72 hour period preceding my appointment time or if miss my appointment. I understand Epione’s lateness policy, which I am responsible to pay for the time I reserve with the therapist, regardless of the time I arrive and I am ready for my appointment. I understand that fees and hours of operation are subject to change without notice

Additional Consent Applicable to Insurance Plan Members Only

Information that we collect and disclose about you, and if applicable, your spouse and/or dependents, is used by the insurer and/or plan administrator and their service provider(s) for the purposes of assessing your claims, underwriting, investigating, auditing and administering the group benefits plan, including the investigation of fraud and / or plan abuse.  

Authorization and Consent

I authorize my healthcare provider to collect, use and disclose personal information concerning any claims submitted on my behalf with the insurer and/or plan administrator and their service provider(s) for the above purposes.  I authorize the insurer and / or plan administrator and their service provider(s) to: 

Use my personal information for the above purposes.

Exchange personal information with any individual or organization, including healthcare professionals, investigative agencies, insurers and reinsurers, and administrators of government benefits or other benefits programs when relevant for the above purposes.

Exchange personal information concerning any claims submitted with the plan member or a person acting on behalf of the plan member.

Exchange personal information for the above purposes electronically or in any other manner.

I understand that personal information may be subject to disclosure to those authorized under applicable law.

I agree that a photocopy or electronic version of this authorization shall be as valid as the original, and may remain in effect for the continued administration of the group benefits plan.

 
I hereby assign benefits payable for the eligible claims to the Provider responsible for submitting my claims electronically to the group benefits plan and I authorize the insurer/plan administrator to issue payment directly to the Provider. In the event my claim(s) are declined by the insurer/plan administrator, I understand that I remain responsible for payment to the Provider for any services rendered and/ or supplies provided.

I acknowledge and agree that the insurer/plan administrator is under no obligation to accept this Assignment, that any benefit payment made in accordance with this Assignment will discharge the insurer/plan administrator of its obligations with respect to that benefit payment, and that in the event the benefit payment is made to me, the insurer/plan administrator will also be discharged of its obligation with respect to that benefit payment.

I understand that this Assignment will apply to all eligible claims submitted electronically by the Provider and that I may revoke it at any time by providing written notice to the insurer/plan administrator. If I am a spouse or dependent, I confirm that I am authorized by the plan member to execute an assignment of benefit payments to the Provider.