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(416) 895-5674info@dcrmt.com438 University Ave, Unit #104

Droughan Costello

Registered Massage Therapy

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Prior to your first appointment, please complete the online Health History & Policy Form below.

If you would prefer to complete the forms by hand, they are also available for download. Prior to your first appointment, please print, complete, scan then email to info@dcrmt.com or complete and bring them with you to your first appointment.

For information on direct billing to your private insurance, please review this post.

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Privacy Policy

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Consent & Cancellation Policy

Consent and Cancellation Policy form image

Health History

Health History form image

Health History & Policy Form

Today's date (YYYY/MM/DD) *

Name: *

First

Last

Phone # *

Email: *

Residence address: *

Occupation: *

Date of Birth (YYYY/MM/DD)

Have you received massage therapy before? *

Did a health care practitioner refer you for massage therapy? *

If yes, please provide their name and address:

Cardiovascular:

High blood pressure
Low blood pressure
Chronic congestive heart failure
Heart attack
Phlebitis / Varicose veins
Stroke / CVA
Pacemaker or similar device
Heart disease

Please indicate conditions you are experiencing or have experienced.

Is there a family history of any of the above? *

Respiratory:

Chronic cough
Shortness of breath
Bronchitis
Asthma
Emphysema

Please indicate conditions you are experiencing or have experienced.

Is there a family history of any of the above? *

Infections

Hepatitis
Skin conditions
TB
HIV
Herpes

Please indicate conditions you are experiencing or have experienced.

Other conditions

Loss of sensation
Diabetes, onset
Allergies / Hypersensitivity
Epilepsy
Cancer
Skin conditions
Arthritis

Please indicate conditions you are experiencing or have experienced.

If yes to any of the above, please explain (where? what?)

Eg: type of reaction?

Is there a family history of arthritis? *

Head / Neck:

History of headaches
History of migraines
Vision problems
Vision loss
Ear problems
Hearing loss

Please indicate conditions you are experiencing or have experienced.

* For women:

Pregnant
Gynaecological conditions

Please indicate conditions you are experiencing or have experienced.

* If yes to any of the above, please explain (due date? what?)

Overall, how is your general heath? *

Primary care physician and their address: *

Current medication(s) and condition it treats:

Are you currently receiving treatment from another health care professional?

If yes, for what?

Do you have a scheduled surgery? *

If yes, please specify date and nature of surgery:

Do you have an injury? *

If yes, please specify date and nature of when it happened:

Do you have any other medical conditions? *

Eg: digestive condition, haemophilia, osteoporosis, mental illness

If yes, please specify:

Do you have any internal pins, wires, artificial joints or special equipment? *

Eg: digestive condition, haemophilia, osteoporosis, mental illness

If yes, please specify (what? where?)

What is the reason you are seeking massage therapy? *

Please include the location of any tissue or joint discomfort

Informed Consent Policy: *

I am providing my consent to receive Registered Massage Therapy treatment(s) from Droughan Costello Registered Massage Therapy. I understand that treatments may include assessment of my soft tissue and joints, stretching or strengthening exercises as indicated by my condition. I understand that my therapist will discuss the treatment plan with me to ensure that I receive a safe and effective treatment. I know it is my right to discuss any component of my treatment with the therapist and that my consent can be rescinded at any time.

Cancellation & Late Arrival Policy: *

To avoid charges, I request a minimum of 24 hours notice for cancellation. A 100% cancellation fee may be charged if you do not show up for your appointment. This is done in fairness both to clients who would otherwise have wanted the appointment and to the therapist, who is not paid if they do not perform the session. As a courtesy to everyone, I thank you for being prompt. Late arrivals can only be extended to the time remaining in the scheduled session. I have read and understood the informed consent, cancellation and late arrival policy.

Sign-up to receive our email newsletter? *

Yes, please.
No, thanks.

Name

Location

438 University Ave, Unit #104 M5G 2K8

(416) 895-5674

Hours

SUN – CLOSED
MON – 2PM – 6PM
TUES – 12PM – 6PM
WED – 10AM – 6PM

THU – CLOSED
FRI – CLOSED
SAT – CLOSED

© 2023 Dru Costello Registered Massage Therapist RMT. All Rights Reserved.

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