100 Westcreek Blvd. Unit 1

Brampton Ontario L6T 5V7

Located inside  Varsity Training Centre

Clinic: 905-820-6262 | Fax: 1-289-975-5122 | info@royalclinic.ca

Move Better, Perform Better.

First Visit

For your initial session, please note that completing the ONLINE Intake / Health history form must be completed. To ensure that your entire session is focused on your treatment, we strongly recommend filling out the form in advance as it is sent to you on your initial booking. This approach enables us to dedicate more time to your care, with a thorough consultation based on the form to ensure the treatment is perfectly tailored to your needs.

If there are changes to your healht, it is the patient's responsibility to update contact details and current health status with your health care provider. Maintaining the accuracy of this information is crucial for us to provide you with the best possible care.

Zero Tolerance Policy
Our policy enforces a strict zero-tolerance stance on verbal abuse, sexual harassment, bullying, and any form of inappropriate comments or behavior. We are committed to maintaining a safe and respectful environment for everyone. We reserve the right to discharge patient's from our care on a need-by-need basis if this policy is activated by the practitioner's interpretaion from a patient's action(s). We strictly afford the right to enforce the boundaries of this policy with the appropriate authorities and issue actions accordingly. 

Personal Hygiene / Illnesses
Personal hygiene is fundamental to maintaining both cleanliness and proper grooming of the external body. To ensure a respectful and comfortable environment for your therapist, we kindly ask you to:
– Ensure personal cleanliness is maintained at all times.
-Practice good oral hygiene to ensure fresh breath.
-Apply deodorant to reduce body odor, keeping the environment pleasant for both you and your therapist.
-Wash your hands thoroughly, promoting a hygienic space for your treatment.

Should you be experiencing a fever, cough, flu/cold symptoms, or any other contagious conditions, we respectfully ask that you call to reschedule your appointment. Receiving treatment can be contraindicated and may worsen your symptoms. Our priority is the health and safety of all our clients and staff.

Risks to Treatment(s)
Like any healthcare intervention, Chiropractic and massage therapy comes with certain inherent risks. While uncommon, possible side effects can range from bruising, muscle sprains, strains, spasms, to mild soreness and skin irritation. Additionally, although rare, there are specific concerns such as miscarriages, labor induction, and the temporary exacerbation of symptoms. Please be advised that Royal Chiropractic and Sports Injury Clinic holds no liability for any adverse effects resulting from treatment. It’s important for clients to be aware of these risks to make informed decisions about their healthcare.

Privacy, Sharing of Information
I authorize the clinic and its associated health professionals to collect my personal, medical, financial information as documented above. In addition, I authorize the clinic and its associated health professionals to communicate with my family doctor and/or referring doctor and/or other health care professionals as deemed necessary for my beneficial treatment. I also understand that my personal and medical information is confidential and may be discussed by insurance companies that are involved in billing practices, and I understand that the clinic may be contacted by insurance companies to inquire about claims and give full consent to to do.

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. Patients who provide less than 24 hours notice, or miss their appointment, will be charged their FULL visit fee for cancellation.

Benefits of Assignment and Manual and Electronic Submission Consent

I hereby assign benefits payable for the eligible claims to the Provider responsible for submitting my claims manually and / or electronically to the group benefits 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 payment to the Provider for any services rendered and/ or supplies provided.

I acknowledge and agree 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 obligations 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 manually and / or 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.

Personal information that we collect and disclose about you, 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 the investigation of fraud and / or plan abuse.

Authorization and Consent I authorize my 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 insurer and / or plan administrator and their service provider(s) to: use my personal information for the above purposes. Exchange personal information with any individual or organization, including healthcare professionals, investigative agencies, insurers and reinsurers, and administrators of government benefits or other benefits programs when relevant for the above purposes. Exchange personal information concerning any claims submitted with the plan member or a person acting on behalf of the plan member. Exchange personal information for the above purposes manual or electronically or in any other manner.

I understand that personal information may be subject to disclosure to those authorized under applicable law.

I agree that a photocopy or electronic version of this authorization shall be as valid as the original, and may remain in effect for the continued administration of the group benefits plan.

Additional Consent Applicable to Plan Members Only I confirm that I am authorized by my spouse and/or dependents, if any, to disclose personal information about them to 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/or plan administrator and their service provider(s) to disclose information about their claims to me, for the purposes of assessing and paying a benefit, if any, and managing the group benefits plan. I also authorize my spouse and/or dependents to assign benefit payments under the plan to the healthcare provider. In the event there is suspicion and/or evidence of fraud and/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.

Agreement to Terms
I hereby give my agreement and consent to undergo assessment and treatment. I confirm that I have thoroughly read the provided information and accurately disclosed all relevant past and present medical conditions. I acknowledge and consent to the sharing of my medical information among the healthcare professionals involved in my care and treatment, understanding the necessity for such exchanges to ensure comprehensive care at the Royal chiropractic and Sports Injury Clinic. I am aware that all client information is treated with strict confidentiality, and any release of this information outside of the clinic will require my explicit written authorization, unless otherwise agreed upon within Benefits of Assignment and Manual and Electronic Submission Consents.

I accept the responsibility to proactively inform my medical provider including but not limited to Chiropractor, massage therapist of any changes in my health history. I understand that the planning and execution of all treatments will be conducted in consultation with my therapists, based on my informed consent. I am aware of the potential risks associated with treatments as previously outlined.

I acknowledge the missed appointment and cancellation and rescheduling policy and agree to incur the specified fees for missed appointments if I fail to cancel or reschedule within the 24-hour window prior to my appointment or if I miss my appointment altogether.

I understand that the clinic’s fees and hours of operation are subject to change without prior notice, and I agree to abide by these and all other policies as stated.