Patient Intake Form

Patient Information

First Name

Last Name

Date of Birth

AHS No.

Address

Postal Code

Home Phone No.

Cell Phone No.

Work Phone No.

Gender

Male Female

Emergency Contact Name/Relation

Emergency Contact No.

Extended Health Care Benefits/Insurance Information

Private Insurance (Manulife, Green shield etc.) MVA WCB Self Pay

Name of the Insurance

Policy No. & Member ID No.

Claim No.

Date Of Loss

Coverage

Primary/Secondary

Claims Representative (If Applicable)

Claims Representative’s Email

Claims Representative’s No.

Physician Information

Physician’s Name

Clinic

Phone No.

Address

How did you hear about us?

Internet Physician Friend /Relative Other

Medical History

Have you had any surgeries? Please provide detail

List of current medication

Are you pregnant?

YES NO

If yes, please note any and relevant details

Release of Medical Record

Acknowledgement and Cancellation policy

Patients are responsible for providing 24 hours’ notice for appointment cancellations. If you cancel without notice, there will be a $30 cancellation fee.

I acknowledge that if I do not provide 24 hours’ notice, I may be charging a cancellation fee. I also acknowledge that the third-party funders may not pay for cancellation charges I may incur, and that I may be personally responsible for paying such cancellation charges.

Billing and Payment

I authorize Monterey Park Physiotherapy to submit claims on my behalf to my insurance company and I am responsible to pay any co-payment or any outstanding balance to services at each time of the appointment upon arrival. In the event my insurance company denies the payment for any reason, I would be solely responsible to pay my services. OR, If the client does not carry any insurance coverage, then the client is fully responsible to pay the complete fee amount for his/her Physiotherapy services at each time of appointment upon arrival.

For MVA, inside protocol (within 90 days of accident), Clinician/Clinic may provide and claim for two treatments visits on the same day while treating multiple body part during a single attendance at the practice setting. Clinic clearly communicates applicable fees to clients and payors prior to the provision of services. Client may ultimately attend the practice setting less than the number of visits allocated in the DTPR, due to the use of multiple treatment visits during a single attendance.

Treatment Information and Consent

Physiotherapy treatment techniques may include but are not limited to: manual techniques including spinal manipulation, electrotherapeutic modalities, shockwave Therapy, Laser etc. and exercise prescription as well as other techniques such as acupuncture/IMS/Dry needling. A number of these may be recommended during your treatment session. As your participation in all aspects of your program is imperative to its success, it is policy of Monterey Park Physiotherapy to ensure benefits, side effects and potential complications of each chosen modality are explained to you by your therapist immediately so they can explain the treatment rationale and/or modify your program appropriately. If at any time you choose not to participate in the program or any portion of it, you must inform your physiotherapist immediately.

I understand and agree with the criteria above and as such agree to participate in an assessment and treatment program at Monterey Park Physiotherapist. I understand that for duration of my treatment, my consent may be withdrawn at any time and understand that I must inform my physiotherapist.

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