Health History and Consent Forms

Forms

 

Come to your first appointment 10-15 minutes early to fill out Health History and Consent for treatment forms. Or you can print the forms here and complete them before you arrive for your first appointment. 

Health History LB.pdf
Adobe Acrobat document [662.7 KB]
Informed Consent LB.pdf
Adobe Acrobat document [437.8 KB]
Receipts
A receipt will be provided for each visit at the time of visit. If you have registered Masage 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 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 fill out the consent form when you arrive or print it out and complete before you arrive at your appointment. Greenshield has a separate consent form and all other companies use the same form.
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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