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    • FAQs
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    • Forms
    • Safety Plan
    • Contact

(604) 431-0005

  • Home
  • FAQs
  • What's new?
  • Fee Schedule
  • The Therapists
  • Benefits
  • Forms
  • Safety Plan
  • Contact

East Vancouver Therapeutic Massage Clinic

East Vancouver Therapeutic Massage ClinicEast Vancouver Therapeutic Massage ClinicEast Vancouver Therapeutic Massage Clinic

Please read the sample consent forms carefully. Each form will be sent to patients electronically once they are booked for an appointment. A therapist will discuss each consent with patients when they attend their initial appointment (new patients and first appointments post COVID-19 shutdown) and require a signature.

Sample Consent Forms

Sample consent form COVID-19

  

East Vancouver Therapeutic Massage Clinic


Patient’s Name


· I agree to wear a mask during my entire visit to East Vancouver Therapeutic Massage Clinic


· I will wash my hands upon entry/re-entry into the clinic and promptly after my treatment is 

  finished


· I will wait in my vehicle or outside and only come in when indicated by my RMT


· I will enter the clinic alone unless I require physical and/or communication support


· I will strictly follow the 2 metre physical distancing rules within the clinic wherever possible


· I will leave promptly after my appointment


· I will read the new protocols available on the clinic website www.eastvancouvermassage.com

  and follow all of the necessary steps to prevent the spread of COVID-19


· I understand my RMT may refuse to provide treatment when the risks of receiving or giving

  a treatment outweigh the possible benefits of treatment


The information listed on this page is based on current recommendations from health and safety regulatory bodies. The content is subject to change due to the unknown characteristics of COVID-19 and the global pandemic. A new signature is required with any change to the consent form.


I verify the information I have provided on this form is truthful and accurate. I have read and fully understand that ANY massage therapy treatment involves some risk of COVID-19 transmission. I voluntarily give consent to receive massage therapy during this COVID-19 

pandemic.



Patient Signature______________________  Date___________________

Sample informed consent form

East Vancouver Therapeutic Massage Clinic

Patient's name 

  • Consent to treatment areas circled below
  • Any areas not to be treated are crossed off and bold

  

  •  I agree to allow my RMT to share the contents of my patient record with other RMTs working at East Vancouver Therapeutic Massage Clinic for clinical/legal/educational purposes only. Information will only be released to a third party with my signed consent.

  •  I agree to the treatment as outlined on the above anatomical diagram. I understand my treatment plan may change and that my RMT will discuss any new areas to be treated. I have crossed off any areas on the above anatomical diagram that I do NOT want to be treated 

  •   The risks of treatment on the circled areas have been discussed with my RMT.


  •  I understand I have the RIGHT TO WITHDRAW CONSENT AND HAVE THE TREATMENT STOP AT ANY TIME. I understand I have the right to ask my RMT question at any time about my treatment plan.



Patient Signature___________________________________ Date____________________________

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