longlake_Consent

PERSONAL INFORMATION
Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Preferred Pronouns
Address
Phone Cell
Phone Home
Phone Work
Email Address
example@example.com
MSP Health Care Card
Family Physician
Date of Injury/Onset of Pain

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Area Being Treated
Occupation
Employer
Emergency Contact
Emergency Contact Phone #:
Format: (000) 000-0000.
Who do we have to thank for referring you to our clinic
FUNDING INFORMATION
Name of Insurance Plan
Policy/Contract ID
Policy Holders Name
Member ID
Policy Holder's DOB
WSBC Claim #
WSBC Case Manager
ICBC Claim
ICBC Adjuster
ICBC Adjuster`s Phone #
Format: (000) 000-0000.
Group
Policy
CONSENT TO TREATMENT: I authorize the physiotherapists and kinesiologists at Long Lake Physiotherapy to assess and treat as appropriate the condition for which I am here today. Physiotherapy treatment may include manual therapy, Intramuscular Stimulation (IMS), acupuncture, electrotherapeutic modalities, exercise, as well as other techniques. If at any time I choose not to consent to treatment, I will inform my physiotherapist immediately.
CONSENT TO RELEASE INFORMATION

I consent to the release of information within my clinical chart to the following parties:
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: