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Date: November 22, 2019

Please select who will be participating...
AdultMinor
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First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Information

Is there a specific reason for selecting this treatment?

Relaxation
Muscle Tension
Arthritis
Other

Which of the following conditions apply to you? (past or present)

*MUST be filled in, regardless of service type*
Allergies *
Yes
No
If Yes, please select type:
Nut / Seed Allergies
Latex
Other (please identify)
Asthma
Arthritis or Bone Fractures (please identify)
Bruise Easily
Cancer / Related Treatments (please identify)
*Diabetes (please identify) *
Yes
No
Digestive Condition
Dizziness / Negative reaction to heat
Epilepsy
Head/Neck Trauma
Heart Condition
High Blood Pressure
Kidney Disease
Numbness / Tingling / Hypersensitivity (where?)
Pregnancy (how many months?)
Recent Surgery (please identify)
Skin Conditions / Lesions / Plantar Warts/ Infections
Soft Tissue Sprains or Strains (please identify)
Spinal Disk Injury / Disease

Do you have any other medical conditions or injuries? Are you taking any medications?

No
Yes

Please List:

What is your occupation and hobbies? Please describe what a typical day involves (sitting, lifting etc.)


Province:

MASSAGE CLIENTS ONLY:IF YOU WOULD LIKE US TO DIRECT BILL FOR YOU PLEASE NOTIFY THE FRONT DESK & FILL OUT THE FOLLOWING ASSIGNMENT OF BENEFITS.

*Please note, the decision of coverage is solely your insurance providers*

Assignment of Benefits

I request that payment under my medical insurance program be made to ONE WELLNESS for any services or equipment furnished to me.  I authorize ONE WELLNESS to release any information needed for this claim to the necessary carriers or their intermediates.  I also request that a copy of this authorization be used in place of the original.

Statement of Confidentiality

I authorize the release of necessary medical information to ONE WELLNESS for the purposes of processing this or any related insurance claims.  I also give ONE WELLNESS the authority to make available any requested documents contained in my file to myself and/or other healthcare providers involved in the treatment of my condition.

Agreement

I acknowledge that I am fully responsible for the payment of any services and equipment provided to me by ONE WELLNESS.  I understand that if ONE WELLNESS submits a claim for billed charges to my health plan(s) on my behalf, I am not relieved of my financial responsibility for payment.  In the event that the health plan or any third party payer does not pay the entire billed amount, I agree to pay any remaining balance.

By signing below, I acknowledge and accept the terms and conditions stated above.


Primary Card Holder:

Primary Card Holders DOB:

Insurance Company:

ID Number:

Group Number:

ACKNOWLEDGEMENT 

**Must be completed by guests 18 years of age and older** 

I acknowledge that I am at least 18 years of age and that the treatments provided at One Wellness and Spa are not intended as a diagnosis and do not replace medical treatment. I further acknowledge that the information I have provided is true, accurate and complete and that certain treatments may be refused to me on the basis of the information provided herein.

First Client's Signature*
Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
How did you hear about us?
Click to customize checkboxes *
Cam Clark Ford
Friend
Google
Roam Transit
Social Media
Hotel Front Desk
Web Search

If you heard about us through a friend, please let us know their name so we can thank them!
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Is there a specific reason for selecting this treatment?

Relaxation
Muscle Tension
Arthritis
Other

Which of the following conditions apply to you? (past or present)

*MUST be filled in, regardless of service type*
Allergies *
Yes
No
If Yes, please select type:
Nut / Seed Allergies
Latex
Other (please identify)
Asthma
Arthritis or Bone Fractures (please identify)
Bruise Easily
Cancer / Related Treatments (please identify)
*Diabetes (please identify) *
Yes
No
Digestive Condition
Dizziness / Negative reaction to heat
Epilepsy
Head/Neck Trauma
Heart Condition
High Blood Pressure
Kidney Disease
Numbness / Tingling / Hypersensitivity (where?)
Pregnancy (how many months?)
Recent Surgery (please identify)
Skin Conditions / Lesions / Plantar Warts/ Infections
Soft Tissue Sprains or Strains (please identify)
Spinal Disk Injury / Disease

Do you have any other medical conditions or injuries? Are you taking any medications?

No
Yes

Please List:

What is your occupation and hobbies? Please describe what a typical day involves (sitting, lifting etc.)


Province:

MASSAGE CLIENTS ONLY:IF YOU WOULD LIKE US TO DIRECT BILL FOR YOU PLEASE NOTIFY THE FRONT DESK & FILL OUT THE FOLLOWING ASSIGNMENT OF BENEFITS.

*Please note, the decision of coverage is solely your insurance providers*

Assignment of Benefits

I request that payment under my medical insurance program be made to ONE WELLNESS for any services or equipment furnished to me.  I authorize ONE WELLNESS to release any information needed for this claim to the necessary carriers or their intermediates.  I also request that a copy of this authorization be used in place of the original.

Statement of Confidentiality

I authorize the release of necessary medical information to ONE WELLNESS for the purposes of processing this or any related insurance claims.  I also give ONE WELLNESS the authority to make available any requested documents contained in my file to myself and/or other healthcare providers involved in the treatment of my condition.

Agreement

I acknowledge that I am fully responsible for the payment of any services and equipment provided to me by ONE WELLNESS.  I understand that if ONE WELLNESS submits a claim for billed charges to my health plan(s) on my behalf, I am not relieved of my financial responsibility for payment.  In the event that the health plan or any third party payer does not pay the entire billed amount, I agree to pay any remaining balance.

By signing below, I acknowledge and accept the terms and conditions stated above.


Primary Card Holder:

Primary Card Holders DOB:

Insurance Company:

ID Number:

Group Number:

ACKNOWLEDGEMENT 

**Must be completed by guests 18 years of age and older** 

I acknowledge that I am at least 18 years of age and that the treatments provided at One Wellness and Spa are not intended as a diagnosis and do not replace medical treatment. I further acknowledge that the information I have provided is true, accurate and complete and that certain treatments may be refused to me on the basis of the information provided herein.

Parent or Guardian's Signature*
Electronic Signature Consent to Treatment*
By checking here, you are consenting to One Wellness' terms and conditions. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.<br><br> The undersigned agrees to indemnify and hold harmless One Wellness, its officers and directors, employees, contractors, and its affiliates and their respective successors and assigns and each other person, if any, who controls any thereof, against any loss, liability, claim, damage and expense whatsoever (including, but not limited to, any and all expenses whatsoever reasonably incurred in investigating, preparing or defending against any litigation commenced or threatened or any claim whatsoever) arising out of or based upon any false representation or warranty or breach or failure by the undersigned to comply with any covenant or agreement made by the undersigned herein or in any other document furnished by the undersigned to any of the foregoing in connection with this transaction.<br><br> One Wellness is committed to diversity and to equal opportunity inclusion. One Wellness does not discriminate on the basis of race, creed, color, ethnicity, national origin, religion, sex, sexual orientation, gender identity and expression, height, weight, physical or mental ability, veteran status, military obligations, or marital status. This includes but it not limited to; change rooms, bathroom facilities, usage of the fitness center and treatment areas. This policy applies to all One Wellness employees, guests, members, clients, and contractors.


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