Order Number Client Information Full Name * Your Email * Date of Birth * Are you the primary insured member on this plan? * Yes No Insurance Company Insurance Company * Canada Life Chambers of Commerce CINUP ClaimSecure Cowan Desjardins First Canadian Group HEALTH GroupSource Industrial Alliance Johnson Insurance Johnston Group Manion Manulife Maximum Benefit Sun Life Policy Number * Member ID * Treatment for Accident Are we treating injuries caused by an accident? * Yes No Prescription Do you have a physician's prescription/referral for massage therapy? * Yes No Authorization * I authorize Muscle Matters to direct bill my insurance company for my massage therapy treatments. I also understand that if for any reason my insurance company refuses payment, I am required to pay for these treatments. I recognize that the clinic’s cancellation policy will not be waived due to insufficient benefits.