Intake From

Your information will be kept confidential and is subject to appropriate data privacy laws.

Please Write Your Full Name (or Guardian's Name) as an Electronic Signature *
Phone Number (e.g. 4167223393) *
Email Address (e.g. *
1. Date of Birth *
2. Sex *

3. Address (Street and Number, Include Unit # If Applicable) *
4. Postal Code *
5. City and Province (e.g. Toronto, ON) *
6. I Provide Consent to be Contacted (e.g. appointment reminders/notifications, etc) *

7. How Did You Hear About Us? *

8. Your General Health History (check all that applies) *

9. List Any Allergies (if applicable) *
10. Current Medications/Supplementation (if applicable) *
11. What Would You Like Us to Address? (check all that applies) *

12. *If Applicable* What is Your Current Pain/Discomfort Level? (0=no pain, 10=worst pain imaginable) *

13. Enter Initials Here: *
14. Consent to Assessment and/or Treatment *
Your health information will be kept confidential and is subject to appropriate data privacy laws. We require this information so that we may better care for you and determine if treatment interventions in our clinic can help you. If we do not sincerely believe your condition will respond satisfactorily, we will not accept your case.

Physiotherapy, chiropractic treatment, massage, and athletic therapy has been subject to evidence-based reports and multi-disciplinary studies, as they have been demonstrated to be highly effective treatments for various symptoms.

As part of these treatments, certain procedures and devices may be utilized such as the use of heat, ice, electrotherapy, ultrasound, shockwave therapy, manual therapy, mobilization, manipulation, acupuncture/needling, custom bracing and orthotic insoles. As part of a rehabilitation program, physical exercise, testing procedures, devices and equipments may be utilized, including, but not limited to free weights, weight machines, cardiovascular and functional physical tasks.

Prior to the rehabilitation session, I will have the opportunity to discuss with the Doctor of Chiropractic/Physiotherapist/Massage therapist and/or other clinical staff, regarding the nature and purpose of the treatments. I understand the intervention results are not always guaranteed.

I further understand and I am informed that there are some risks to the treatments including, but not limited to; muscle strains, sprains, stroke, disc injuries, fractures, dizziness, nausea, heart attack and burns and skin irritation. The risk of injuries or complications from chiropractic, physiotherapy, and massage therapy are substantially low. These interventions are considered to be generally safe and effective compared to other associated treatments, such as medications and procedures given for the same symptoms. I will be made aware that appropriate tests will be performed to help identify if I may be susceptible to risk or injury.

Treatment Liability:
I acknowledge that I may be engaging in physical exercise while attending Studio Athletica Sports Medicine, which could cause injury. I hereby state that I will be voluntarily participating in these activities and I hereby assumes all risk of injury which might result from these activities. I hereby waive and release any claims that I may have against the club/clinic, its employees or agents for injury sustained by the clinic as a result of these physical exercises and activities. I hereby acknowledge that I have carefully read this waiver and release liability. I fully understands that it is a release of liability of the club/clinic and agree that such a waiver and release is reasonable and, proper based of the nature of the clubs/clinics.

*I will immediately notify the Physiotherapist, Chiropractor, or Massage Therapist of any changes in my pregnancy or medical status.
*I accept the fact that there is no guarantee of the effectiveness of the treatment.
*I am aware that I may withdraw this consent and discontinue treatment at anytime.
*I have read and understand the above statements, and hereby provide consent to an examination and/or treatment.
15. Today's Date *

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403 Parliament St,
Toronto, ON M5A 3A1


Monday - Friday
9AM - 6PM
10AM - 4PM


+1 (416) 274-7979

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