Health History and Consent Forms

Forms

                                                        PLEASE TAKE NOTE!

 

All the forms you need for Yvonne De Villiers RMT,CSI  will be available online for completion.

It will be sent to you in your confirmation or reminder e-mail. Please read the whole e-mail for all the details.

Gwen McLean RMT,CSI will send you the paperwork online as soon as you book your first appointment.  If you have any difficulty please contact the clinic. 

Receipts
A receipt will be provided for each visit at the time of visit. If you have Registered Massage Therapy coverage through your Extended Health Care, Structural Integration will be reimbursed accordingly.
 
MVA and WSIB 
Our clinic is not able to take WSIB or MVA claims. 
 
Extended Health Insurance
Each insurance plan is different. Please check to make sure you are set up for us to bill online. If your plan requires you to have a referral from your physician for Registered Massage Therapy coverage please bring the referral with you.  
 
If you would like us to direct bill your insurance company we need your consent to bill them and receive the payment. You can access them in the e-mail you will receive and complete it before you arrive at your appointment. Greenshield has a separate consent form and most other companies use the same form. (TELUS HEALTH)
Informed Consent LB.pdf
Adobe Acrobat document [437.8 KB]
Health History LB.pdf
Adobe Acrobat document [672.2 KB]
Health Insurance Consent
Electronic Transmission Authorization an[...]
Adobe Acrobat document [507.6 KB]
Greenshield Consent
GS Electronic Transmission Authorization[...]
Adobe Acrobat document [46.5 KB]

Questions About Our Treatments?

Call us at 519 601 6602 or submit your questions using our contact form.

Contact Us

Living Balance Clinic

Unit 2 - 551 Knights Hill Road

Lower Level

London, Ontario

 N6J 3A1

  

Phone: 519-601-6602
Email: mail@livingbalanceclinic.ca

Questions?

All the information you need to know for your first appointment will be sent with your first confirmation e-mail when you book online. If you have any other questions or concerns please contact us here or call. Our professional team will be happy to help you.

 

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