Mackie Physiotherapy
    Osteopath & Massage Registration Form
    Fee For Service/Group Insurance Plan
    This clinic is a fee-for-service clinic. I, the patient, will pay Mackie Physiotherapy for my treatment directly, and, if applicable, will submit the receipt to my group insurance plan for coverage of the treatment expense unless previously done so electronically by the clinic. Please indicate your understanding of this by checking below.
    Cancellation/Missed Appointments
    Mackie Physiotherapy reserves the right to charge a fee for missed appointments, or for appointments that are cancelled with less than 24 hours notice. These fees are to be paid by the patient, not by an insuring party. Please be respectful of the clinicians, the clinic, and your rehab process and make every effort to attend your scheduled appointments. Please also be aware that, as the clinic is very busy, it is difficult to reschedule appointments.
    • Cancellation fee for cancellations occurring with less than 12 hours notice is $10.
    • Missed appointment fee will be the full cost of the appointment.

    Please be respectful of the clinicians, the clinic, and your rehab process and make every effort to attend your scheduled appointments.  Please also be aware that, as the clinic is very busy, it is difficult to reschedule appointments.   Also, for your awareness, if there is a missed appointment or cancellation with less than 24 hours notice, massage therapists on commission-based earnings receive no income.

    IF YOU ARE EXPERIENCING ANY COVID-19 SYMPTOMS, PLEASE LET US KNOW AND WE WILL CANCEL YOUR APPOINTMENT AND REBOOK YOU FOR A LATER DATE.

    Consent for Examination & Treatment

     
    I understand that the Osteopathic Therapist is providing osteopathic therapy services within their scope of practice as defined by the Osteopathic Therapist Association of Saskatchewan, Inc.
     
    I hereby consent to my Therapist to treat me with osteopathic therapy for the above noted purposes including such assessments, examinations and techniques, which may be recommended, by my Therapist.
     
    I acknowledge that the Therapist is not a physician and does not diagnose illness or disease or any other physical or mental disorder.  I clearly understand that osteopathic therapy is not a substitute for a medical examination.  It is recommended that I attend my personal physician for any ailments that I may be experiencing.  I acknowledge that no assurance or guarantee has been provided to me as to the results of the treatment.  I acknowledge that with any treatment there can be risks and those risks have been explained to me and I assume those risks.
    I acknowledge and understand that the Therapist must be fully aware of my existing medical conditions.  I have completed my medical history form as provided by my Therapist, and disclosed to the Therapist all of those medical conditions affecting me. It is my responsibility to keep the Osteopathic Therapist updated on my medical history.  The information I have provided is true and complete to the best of my knowledge.
     
    I authorize my Therapist to release or obtain information pertaining to my condition(s) and/or treatment to/from my other caregivers or third party payers.
     
    I have read the above noted consent and I have had the opportunity to question the contents and my therapy.  By signing this form, I confirm my consent to treatment and intend this consent to cover the treatment discussed with me and such additional treatment as proposed by my Therapist from time to time, to deal with my physical condition and for which I have sought treatment.  I understand that at any time I may withdraw my consent and treatment will be stopped

    Patient Health History
    Please indicate which of the following conditions you have experienced, and if you are currently experiencing them.
    Respiratory:
    Cardiovascular:
    Head & Neck:
    Skin:
    Digestive:
    Soft Tissue & Other:
    Women Only:
    Additional Questions:
    Current Condition: