This form is used to collect personal, health, and insurance information necessary for assessment, treatment planning, insurance claims submission, and clinic record keeping. It also documents the client’s informed consent for massage therapy services, the electronic submission of insurance claims, the collection, use, and disclosure of personal information, and the assignment of insurance benefits where applicable. All information collected forms part of the client health record and is maintained in accordance with applicable laws and professional regulatory requirements.
Provider Information: Vaid Rubal’s Clinic Ltd, 12-351 Parkhurst Sq, Brampton, Ontario, L6T 0C2 905-874-3333
