Patient Intake FormPlease complete the patient intake form below in advance of beginning your digital physiotherapy treatment. General InformationName* First Last Guardian (if under 18) Gender Address* Street Address Address Line 2 City Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Date Of Birth* Month Day Year Home Phone*Cell Phone*Emergency Contact Name, # & Relation*Referring Doctor Family Doctor Area of Injury/Diagnosis* May we contact you via email?* Yes No Email Address* Billing InformationPrimary Insurance Provider Primary Insurance Policy # Primary Insurance ID # Secondary Insurance Provider Secondary Insurance Policy # Secondary Insurance ID # WCB/MPI InformationWCB or MPI? WCB MPI Claim Number Date Of Incident Month Day Year Adjustor Name ReferralHow did you find out about us?*(Check all that apply) Friend/Relative Internet Print Ad Been Here Before Medical Professional Other Medical HistoryDo you presently or have you ever suffered from any of the following?(Check all that apply) Heart Problem HIV/AIDS High Blood Pressure Arthritis High Cholesterol Fainting Stroke Depression Lung Problems Anxiety Cancer Seizures/Epilepsy Diabetes Kidney Problems Osteoporosis Fracture Skin Disease/Sensitivity Circulatory Disorder Asthmas Hepatitis Could you be pregnant?* Yes No Do you have a pacemaker?* Yes No Please list any medications you are currently taking:Do you suffer from any allergies?(if so, please list)This spot is specifically held for you. Late cancellations prevent others from attending, delays your recovery and opens time in the therapists working schedule. If you cancel an appointment within the 24-hours, or do not come to an appointment without notice, the following actions will be taken: First Late Cancellation/No-Show Second Late Cancellation/No-Show Third Late Cancellation/No-Show Warning with reminder about cancellation policy $40 cancellation fee will be charged to you and payment is due before treatment can continue We will no longer continue with treatment, and you will be discharged. A 24 hour notification is required to cancel or reschedule an appointment. I understand I will be responsible for a $40.00 fee if insufficient notice is provided. Treatment will not continue until payment is remitted. My signature acknowledges that I accept and understand the above information.Accept Cancellation Policy* By Checking this box, I acknowledges that I accept and understand the above information. Patient Consent*I hereby give consent to Caitlin Trakalo to provide a physiotherapy assessment and treatment based upon our discussed, mutually agreed goals. I understand I am responsible for all costs incurred and that payment is due after each treatment. I consent to having my medical information release to third parties, e.g. Physician, third party insurance companies if necessary. My signature acknowledges that I accept and understand the above information. I agree to the above terms Your Signature*Use your mouse to sign, or your finger if you are on a phone or touch device.CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
