Policies & Consents

If you have any other questions, please contact us for more information.

Cancellation Policy

Your appointment time is reserved just for you. A late cancellation or missed visit leaves a hole in the therapists’ day that could have been filled by another patient. As such, we require 24 hours notice for any cancellations or changes to your appointment. Clients who provide less than 24 hours notice, or miss their appointment, will be charged a cancellation or no show fee.

*Payment of any fees must be made within 24 hours of the missed appointment. Failure to do so will result in any future bookings to be cancelled until payment is made in full. Thank you for your understanding.

Late Arrival Policy

Please arrive 5 minutes before or as close to your appointment start time as possible to allow time for any intake questions your therapist may have. All intake forms be completed online prior to your appointment. Incomplete intake forms or arriving after your appointment time may result in lost time from your treatment as we are unable to exceed that reserved time without affecting the next client session. Full service fees will be charged even when sessions are shortened due to late arrival.

Inappropriate Behaviour Policy

Our manual therapies are for relaxation & therapeutic purposes only. There is absolutely no sexual component to treatment whatsoever. Any insinuation, joke, gesture, conversations or request will result in immediate termination of the session and a refusal of any and all future services. Full-service fees will be charged regardless the length of the session.

Payment Policy

Direct Billing is a service we are happy to provide to our clients, but please note that every Insurance Policy is different and not all plans allow us to direct bill on your behalf.

Some insurance plans may require you to get a referral from your physician, and that most plans have a maximum amount for treatments. We do not have access to see what your plan covers or what is left on your plan.

Consents

Treatment Consent Statement

I understand that services are provided for stress reduction, relaxation, relief from muscular tension and improvement of circulation & energy flow. If I experience pain or discomfort during my session, I will immediately inform my therapist so that pressure/strokes or any other aspect of the treatment can be adjusted to to my level of comfort/satisfaction. While rare, some clients may experience short-term aggravation of symptoms or bruising as a result of the treatment given. I understand that the services offered are not a substitute for medical care. I affirm that I have notified the therapist of all medical conditions and injuries. I agree to inform the therapist of any changes in my health. I understand that there shall be no liability on the therapist’s part should I forget to do so. By signing this release, I hereby waive and release the therapist and Urban Massage & Wellness Inc. from any and all liability, past, present & future relating to manual osteopathy & massage therapies including (but not limited to) myofascial/fire cupping, hot stone treatments, Rapid NFR & fascial stretch therapy.

 

Payment is due at time of treatment. In the event your claim(s) are declined or come back as pending by the insurer/plan administrator, you remain responsible for the payment to the provider for any services rendered and/or supplies provided.

Electronic Transmission Authorization & Benefit Consent

We direct bill most insurance companies, however, each plan is different and may not allow us to submit a claim on your behalf. Be sure to verify your plan.

The following statement provides stipulations/consent for Urban Massage & Wellness to submit a claim to third party insurance on your behalf:

Personal information collected and disclosed by the aforementioned clinic, and if applicable, your spouse and/or dependents is used by the insurer and/or plan administrator and their service provider(s) for the purposes of assessing your claims, underwriting, investigating, auditing and administering the group benefits plan, including investigation of fraud and/or plan abuse. I hereby assign benefits payable for the eligible claims to the provider responsible for submitting my claims electronically to the benefit plan and I authorize the insurer/plan administrator to issue payment directly to the provider. In the event my claim(s) are declined by the insurer/plan administrator, I understand that I remain responsible for the payment to the provider for any services rendered and/or supplies provided. I acknowledge that the insurer/plan administrator is under no obligation to accept this assignment, that any benefit payment made in accordance with this assignment will discharge the insurer/plan administrator of its obligation with respect to that benefit payment, and that in the event the benefit payment is made to me, the insurer/plan administrator will also be discharged of its obligation with respect to that benefit payment. I understand that this assignment will apply to all eligible claims submitted electronically by the provider and that I may revoke it at any time by providing written notice to the insurer/plan administrator. If I am a spouse or dependent, I confirm that I am authorized by the plan member to execute an assignment of benefit payments to the provider. I confirm that I am authorized by my spouse and dependents, if any, to disclose personal information about them t the insurer and/or plan administrator and their service provider(s) for the purposes described above and I confirm that my spouse and/or dependents also authorize the insurer and their service provider(s) to disclose information about their claims to me, for the purposes of assessing and paying a benefit, and managing the group benefit plan. I also authorize my spouse and/or dependents to assign benefit payments under the plan to the healthcare provider. In the event of suspicion and/or evidence of fraud, or plan abuse concerning claims submitted, I acknowledge and agree that the insurer and/or plan administrator and their service provider(s) may use and disclose relevant personal information to any relevant organization including law enforcement bodies, regulatory bodies, government organizations, medical suppliers and other insurers, and where applicable my plan sponsor, for the purposes of investigation and prevention of fraud and/or plan abuse. If there is an overpayment, I authorize the recovery of the full amount of the overpayment from any amount payable under the group benefits plan, and the exchange of personal information with other persons or organization, including credit agencies and, where applicable, my plan sponsor, for that purpose. I authorize the clinic and healthcare provider to collect, use and disclose personal information concerning any claims submitted on my behalf with the insurer and/or plan administrator and their service provider(s) for the above purposes. I authorize the plan administrator and service provider(s) to use my personal information for the above purposes, including but not limited to personal information with any individual or organization when relevant for the above purposes; exchanging personal information concerning claims or exchanging personal information for the above purposes electronically or in any other manner. I understand that personal information may be subject to disclosure to those authorized under applicable law and that a photocopy or electronic version of this authorization shall be valid as the original, and may remain in effect for the continued administration of the group benefit plan.

Paediatric Treatment Release

All persons 12 & under are required to have a parent or guardian fill out this form
Please check all boxes below as you read through each statement *All boxes must be checked before we are able to proceed with treatment:

-You agree that you are the parent or legal guardian of the minor receiving treatment(s)
-You understand that you are required to remain at the facility for the entirety of the minor’s treatment(s)
-You will also also be required, if needed, to assist the minor in preparing for their treatment(s)
-We may also request that you remain in the treatment room to supervise all interactions between the therapist and the minor
-You agree that you have competed the intake form and have informed the therapist of any and all medical diagnoses, symptoms, medications and complaints associated with the minor receiving treatment(s)

Accuracy of Information:

I certify that the above medical information is correct to my knowledge and have disclosed any & all health risk factors.

Client’s Consent & Release

I have competed the intake form for the above mentioned minor and informed the therapist of any and all relevant medical history and concerns.

I understand the scope of manual therapy and that it is not meant to diagnose, treat, or cure any conditions and is not a replacement for standard medical care.

I give permission for my minor to receive treatment(s) at Urban Massage & Wellness and agree to all of the above terms.

Hot Stone Contraindications

Hot stone or hot/cold stone massage is not suitable for everyone. You must inform your massage therapist if you have any of the following conditions which may make hot stone massage contraindicated or may require the therapist to alter the treatment.

-Pregnancy
-Diabetes
-Inflammatory skin conditions
-Open wounds or sores
-Hypotension or Hypertension
-Cancer (with or without treatment)
-Varicose Veins
-Under the influence of drugs or alcohol
-Blood clot(s)
-Neuropathy
-Autoimmune Condition (MS, Lups, RA, etc)
-Peripheral vascular disease
-Heat sensitivity
-Compromised immune system
-Edema or Lymphedema
-Cardiovascular disease

Accuracy of Information:

I certify that the above medical information is correct to my knowledge and have disclosed any & all health risk factors.

Client’s Release for Hot Stone Massage:

-I have read and understand the aforementioned conditions which make hot stone massage contraindicated. I understand that I will be receiving hot stone massage as an adjunct form of healthcare only and that this therapy is not meant to replace appropriate medical care. I release the massage therapist and Urban Massage & Wellness Inc of any and all liability for any harm that may unintentionally occur during. my treatment(s).

-I understand the information contained in this form and confirm that I do not have any of the above conditions.

-My condition(s) checked off above are appropriately managed/monitored by my physician. I understand hot stone massage is considered contraindicated. Given this knowledge I hereby consent to receive hot stone massage and take full responsibility of any side effects or harm that may come from my receiving hot stone massage.

Fascial Stretch Therapy

Information and Suggestions:

*Prior to your stretch, please remove jewelry or watches. Pull long hair back with a clip or band *Please wear loose, long, comfortable clothing that allow for freedom of movement
*Feel free to ask your practitioner any questions before, during or after the session. Your practitioner is a highly trained professional and will be happy to make you feel informed and comfortable.

You will need to check the boxes below as you read through each statement:

*I understand that fascial stretch therapy is provided for stress reduction, relaxation, relief from muscular tension and improvement of circulation, range of motion and energy flow.
*If I experience pain or discomfort during the session, I will immediately inform my practitioner so that pressure can be adjusted to my level of comfort.
*I will not hold my practitioner responsible for any pain or discomfort I experience during or after the session.
*I affirm that I have notified my practitioner of all known medical conditions and injuries
*I understand that stretch therapy sessions are designed to assist in greater stretch gains and are non-sexual in nature
*I understand that the services offered at Urban Massage & Wellness are not a substitute for medical care.
*I understand that my practitioner is not qualified to diagnose, prescribe or treat physical or mental illness.

Accuracy of Information:

I certify that the above medical information is correct to my knowledge and have disclosed any & all health risk factors.

FST Treatment Consent & Release:

By signing this consent, I hereby waive & release my practitioner and Urban Massage & Wellness from any and all liability, past, present and future relating to fascial stretch therapy/bodywork.

Myofascial Cupping

Contraindications:

People who are on blood thinners should not experience Myofascial Cupping Massage. If you start taking such medication please inform the therapist so your treatment plan can be adjusted.

*I am on blood thinners (Treatment is not recommended)
*I am on blood thinners, but my condition is under control and my Dr has approved Myofascial

Please check the boxes below as you read through each statement:

*I understand there are no guarantees regarding its use and effects and that I am free to stop the cupping treatment at any time.
*I understand that cupping commonly leaves marks on the skin that vary in pattern and colour (from light to dark purple) and usually last 3 days to a week, and sometimes longer

Accuracy of Information:

I certify that the above medical information is correct to my knowledge and have disclosed any & all health risk factors.

Client’s Release

-I understand and acknowledge that cupping is performed by suction at certain points on the body in attempt to treat bodily dysfunction, to modify or prevent pain perception, and to normalize the body’s physiological functions.

-I am aware and acknowledge that certain adverse effects may result. Including but not limited to: local bruising, pain or discomfort or possible aggravation of symptoms existing prior to cupping treatment.

Fire Cupping Massage Contraindications

Fire Cupping is NOT recommended if you are experiencing any of the following;
-Are/have recently been fasting or have an empty stomach
-Have a burn or sunburn in the area to be cupped.
-Recent trauma, inflamed or infected tissue, bleeding or fracture
-Within 24 hours of a sports injury
-Grade 3 ligament or sprain or tendon rupture
-Prone to bleeding or Hemophilia, purpura hemorrhagic, Leukemia, capillary fragility test positive
-Damaged site of dermatologic disease in the area to be worked, contagious skin disease or serious skin allergies
-Have been diagnosed with Malignant tumors.
-Severe edema, moderate or severe heart disease, heart failure, cirrhosis, ascites of the liver or an active tuberculosis sufferer
-Less than 6 months of pregnancy
-Varicose veins in the area
-Under the influence of drugs and/or alcohol

People who are on blood thinners should not experience Fire Cupping Massage. If you start taking such medication please inform the therapist so your treatment plan can be adjusted.

*I am on blood thinners (Treatment is not recommended)
*I am on blood thinners, but my condition is under control and my Dr has approved Fire Cupping Massage

Please check the boxes below as you read through each statement:

-I understand there are no guarantees regarding its use and effects and that I am free to stop the cupping treatment at any time.
-I understand that cupping commonly leaves marks on the skin that vary in pattern and colour (from light to dark purple) and usually last 3 days to a week, and sometimes longer
-I understand that Fire Cupping should not be combined with aggressive exfoliation, done within 4 hours of shaving, after a sunburn or when I’m hungry or thirsty
-I understand that I should avoid exposure to cold, wet, and/or windy weather conditions, hot showers, baths, saunas, hot tubs and aggressive exercise for 24 hours. Exposure to such extremes can produce undesirable effects and I should avoid such situations.
-I understand that I should avoid caffeine, alcohol, sugary foods and drinks, dairy and processed meats and I should consume an abundance of clean water
-Although uncommon, I understand there are unexpected/rare risks such as bleeding, blisters or burns

Accuracy of Information:

I certify that the above medical information is correct to my knowledge and have disclosed any & all health risk factors.

Client Release:

-I understand and acknowledge that fire cupping is performed by suction through negative pressure by inserting fire into the cup to draw out the oxygen at certain points on the body in attempt to treat bodily dysfunction, to modify or prevent pain perception, and to normalize the body’s physiological functions.
-I am aware and acknowledge that although extremely rare, certain adverse effects may result. Including but not limited to: local bruising, blisters, burns, bleeding, pain or discomfort or possible aggravation of symptoms existing prior to cupping treatment.

Pregnancy Massage Contraindications

Massage therapy during pregnancy has been shown to be beneficial for a number of common complaints such as fatigue, musculoskeletal pain, sciatica, edema, and many others. However, there are some risks associated with specific conditions that may occur during pregnancy.

You must inform your massage therapist if you have or have had in the past any of the following conditions or symptoms which may make massage therapy during pregnancy contraindicated or may require your therapist to alter the treatment:

-History of miscarriage
-Gestational Diabetes
-Cardiac, pulmonary, liver, or renal disorders
-Mother’s age under 20 or over 35
-Pitting edema
-Epilepsy or other convulsive disorders
-Placental or cervical dysfunction
-Abdominal pain
-Leaking of amniotic fluid
-Fever
-Sudden edema/swelling
-Severe headaches
-Preeclampsia
-History of any high-risk pregnancy
-Drug exposure
-Multiples
-Hypertension
-Genetic abnormalities
-Fetal growth retardation
-Bloody discharge
-Sudden weight gain
-Diarrhea
-Decrease in fetal movement over 24-hour period
-Severe nausea or vomiting

Please read through the following statements and check the boxes as consent:

-I have read the aforementioned conditions and symptoms which make massage therapy during pregnancy-contraindicated.
-I have disclosed all high-risk factors of my pregnancy.
-I have discussed with my prenatal healthcare provider/physician any health concerns that I had about receiving massage therapy.
-I agree that my healthcare provider/physician has given me clearance to receive massage therapy.
-I understand that I will be receiving massage therapy as an adjunct form of healthcare only and that this therapy is not meant to replace appropriate medical care.

Client’s Release:

Accuracy of Information:

I certify that the above medical information is correct to my knowledge and have disclosed any & all health risk factors.

I understand the information contained on this form and confirm that

I am receiving medical care including regular check-ups with a licensed healthcare provider
I have not experienced any of the listed symptoms, conditions, or complications.
I am not currently experiencing any of the listed symptoms, conditions, or complications.
I am experiencing a low-risk pregnancy.

Acupuncture

Accuracy of Information:

I certify that the above medical information is correct to my knowledge and have disclosed any & all health risk factors.

Privacy & Sharing of Information:

I authorize the clinic and its associated health professionals to collect my personal and medical information as documented above. in addition, I authorize for my personal and medical information to be shared between the attending Registered Acupuncturist and Urban Massage & Wellness to provide seamless and streamlined care; such information will be kept confidential by all parties in accordance with applicable legislation.

Declaration of Medical Consultation:

Section 8(1) of Alberta’s Acupuncture Regulation stipulates that an acupuncturist shall not undertake the care and treatment of a person unless:

a) that person has already consulted with a physician or, in the case of dental pathology, a dentist about the condition for which care and treatment from the acupuncturist is being sought;
(b) that person has informed the acupuncturist that a physician or dentist has been consulted about the condition; and
(c) the acupuncturist has completed a patient consultation form.

-I have consulted with a physician or dentist (as appropriate) about the condition for which acupuncture treatment is now being sought.

Consent to Treatment Modalities:

Traditional Chinese Medicine utilizes a wide range of modalities to tap into the body’s natural, innate ability to heal to re-establish a balanced state of wellbeing. These classical techniques have endured the test of time, and include acupuncture, cupping, Gua-Sha friction technique, Tui-Na massage and acupressure, and moxibustion, or any combinations thereof. Acupuncture The use of hair-thin, sterile, one-time use disposable needles to promote the body’s natural healing response by inserting them into known acupuncture points. Occasionally, this may produce strong stimulative effects including mild soreness or throbbing, but should not be painful. From time to time, a minute electrical current may be added, producing a very mild tingling sensation.

Cupping A negative-pressure technique performed over the skin to increase blood flow to the affected area, thereby enhancing the cellular regenerative processes of the body.

Gua-Sha A friction technique over muscular tissue to draw stagnant blood out from the capillaries to just beneath the surface of the skin. Light bruising over the affected area is a normal and desired result.

Tui-Na Massage and Acupressure Hands-on manipulation of muscular tissue and acupuncture points. Many of the Tui-Na massage techniques share a common or similar origin as Swedish massage therapy. Muscles are often loosened and relaxed when performed in conjunction with acupuncture.

Moxibustion An application of heat therapy; this can be achieved through many different ways: mainly, topical application of herbs and infrared light therapy. The underlying therapeutic principle is not dissimilar to the use of a hot water bottle or a hot compress over a small area.

The use of any, or a combination, of the modalities may occasionally produce side effects such as light temporary bruising, bleeding, swelling, numbness/tingling, or soreness over the affected areas of the body; and, such effects may persist up to 48 hours after treatment. In extreme, but very rare, instances, needle stick injuries including bent/stuck needles, infection, nerve injury, pneumothorax, or perforation of the peritoneum, may occur.

Furthermore, in pregnant women, Traditional Chinese Medicine modalities can have both positive and negative impacts on the fetus(es) in utero. For example: Positively, specific acupuncture points can help in instances of a breeched baby; negatively, certain acupuncture points are known to induce labour. In order to take the necessary precautions, the attending acupuncturist must be informed of all pregnancy or any possibility thereof.

-I understand the risks associated with the modalities of Traditional Chinese Medicine, and agree to indemnify the attending acupuncturist(s) from all unintended effects.

Infrared Sauna

*Urban Massage & Wellness does not provide medical advice or treatment. Far Infrared Sauna use may or may not be appropriate for you. Please consult your health care provider for medical advice. The information provided is for general information purposes only and does not address individual circumstances or medical conditions. Do not attempt to self-treat any disease with Far Infrared Sauna.

Which of the many benefits of the Infrared Sauna interest you the most?

-Lowering Blood Pressure
-Circulatory Issues
-Psoriasis
-Pain Relief
-Lyme Disease Health
-Acne
-Sleep Health
-Heart Health
-Eczema
-Feeling Better

Consent to use the Infrared Sauna is conditional upon the following intake questions:
Please note the following listed conditions are considered contraindications for the use of the Infrared Sauna. If you answer ‘Yes’ to any of the questions below, you must get a release from your physician before using the Infrared Sauna.

Do you suffer from Congestive Heart Failure? (IR Saunas can be beneficial for this)
Yes / No
Do you have a pacemaker or defibrillator? (Mainly due to magnets in saunas)
Yes / No
Do you suffer from Parkinson’s, Lupus, Hemophilia or Multiple Sclerosis?
Yes / No
Do you have an acutely inflamed injury or a serious injury occurrence in the last 48 hours?
Yes / No
Do you have recent wounds from an injury or surgery?
Yes / No
Do you have a fever?
Yes / No
Are you pregnant?
Yes / No

If you answer ‘Yes’ to any of the questions below, you need to be cautious. We can set your first session at a lower temperature.

Do you have high blood pressure? (IR Saunas can be beneficial for blood pressure)
Yes / No
Are you currently taking diuretics, barbiturates, beta-blockers or anti-histamines?
Yes / No
Do you have a metal pin, rod, artificial joint or any other surgical implants?
Yes / No
Are you currently having a heavy menstrual period?
Yes / No
Do you have a hard time breaking a sweat?
Yes / No
Are you over the age 65?
Yes / No
Are you under the age 18? (must be accompanied by adult)
Yes / No

Reduce The Risk Of Overheating

Please check the boxes below as you read through each statement:

*Exit the sauna immediately if you are dizzy or sleepy
*Discontinue sauna use if you experience pain and/or discomfort
*DO NOT consume alcohol, drugs, or medication prior to, or while using the sauna Drink water before, during and after your infrared sauna session
*You Are Required To Bring Your Own Water Bottle

Accuracy of Information:

I certify that the above medical information is correct to my knowledge and have disclosed any & all health risk factors.

I clearly confirm that I do not have any of the contraindications listed above.

Infrared Sauna Consents:

I understand that these sessions are for the purpose of relaxation and not intended to treat any condition or disease or to take place of medical care or medications.

Release From Liability:

Urban Massage & Wellness Inc is released from any liability in connection with the use of the Infrared Sauna.

 

Book an Appointment 

Book an appointment or contact the Urban Massage & Wellness team to improve your health and wellbeing.