Forms & Policies
24 hours notice is required for canceling any appointment.
Less than 24 hours notice will be considered a missed appointment and a $53 fee will be charged for all missed appointments booked for 1 hour or less. A $85 fee will be charged for all missed appointments booked for greater than 1 hour. Missed appointments without any notice will charged at the full rate of the treatment booked.
Cancellations must be done using the Online Booking System or call/text at (613) 812-8850.
If it is your first appointment, please arrive at least 10 minutes early to fill out a Confidential Case History Form pertaining to your health. Alternatively, you may print and complete the confidential health history form and bring the completed form to your appointment. Your appointment will start with a review of this form prior to your assessment and treatment. Please make sure to arrive early enough to fill out the form so that you do not lose any appointment time.
The Confidential Case History Form requires a copy of Adobe Reader. Download Now.
Your appointment time includes a review of your confidential health history form (for new clients), assessment and treatment.
Each session booked includes a brief assessment of your case prior to the actual treatment. You and Cynthia will mutually agree to what needs to be treated prior to starting your treatment. You may withdraw consent or request to change your treatment at any time.
As a Health Information Custodian (HIC) under Ontario’s Personal Health Information Privacy Act (2004), Cynthia is bound by law and ethics to safeguard your privacy and the confidentiality of your personal information.
It is not the practice of Cynthia DeRoche to buy, sell or trade private information.
Cynthia’s responsibilities include:
- Collect only the information that may be necessary for your care
- Keep accurate and up-to-date records
- Safeguard the medical records in her possession
- Only when it is deemed necessary for your treatment , and with further written permission, will she contact other health care providers outside the clinic
- Information may be shared with another health care provider (including any member of a regulated health profession under the Regulated Health Practioners Act) and organizations on a “need to know” basis only where required for your care (emergencies, serious safety issues)
- Disclose information to third parties only with your express consent, or when necessary for legal reasons
- Retain and destroy records in accordance with the law
Your request for care implies consent for the collection, use and disclosure of your personal health information for purposes related to your care. As noted above, other purposes require your express consent
Your rights include:
- Understand the purposes for the collection, use and disclosure of your personal health information
- Refuse or give consent to the collection, use, or disclosure of your personal health information, except where required by law
- Withdraw or change your consent
- Access to view your records
- Request amendments to your records
- Obtain copies of your records (please request the fees for this service).
- Complain to the Office of the Information and Privacy Commissioner (OIPC) about a custodian’s refusal to give you access to all or part of a health record
- Make a complaint to the Information and Privacy Commissioner about any breach of your privacy