Telma Grant Private Pay Direct Billing

Private Patient: No Direct Billing

Patient Intake Forms Package

Instructions:

1) You must complete and submit this forms package within 35 minutes or it will time out and your entries will be lost. If you close your browser or refresh your screen, your entries will be lost.

2) It might be useful to review the form package before you start so you can get the required information together.

3) Have your OHIP and insurance numbers at hand before you start.

4)We realize you may have to enter the same information more than once (particularly your name Our online form system will not transpose data from page to page.

5) To submit the form package, click on the "Submit" button on the last page

6) If you prefer, we can email you a PDF of the form which you can fill out and print.
HEALTH INTAKE AND HEALTH QUESTIONNAIRE

TEXT AND EMAIL ARE OUR PRIMARY METHOD OF COMMUNICATING WITH PATIENTS. IF POSSIBLE, PLEASE PROVIDE US WITH BOTH YOUR MOBILE AND EMAIL ADDRESS.
Name

FIRST NAMELAST NAME
Middle Name
Preferred Name
EMAIL ADDRESS
example@example.com
DATE OF BIRTH (yyyy/mm/dd)

YearMonthDay
Date
MAILING ADDRESS (we use email for appointment reminders)

Address

Street Address Line 2

CITYState / Province

POSTAL CODE
Home Number
Please enter a valid phone number.
MOBILE NUMBER
WORK NUMBER
EMERGENCY CONTACT: The College of Physiotherapists of Ontario requires that we obtain an emergency contact. Please provide an emergency contact for our records.
FULL NAME
RELATIONSHIP
PHONE NUMBER
Please read carefully. By checking off the box and signing at the bottom you are agree to the following policies

CANCELLATION POLICY:

Patients who do not provide 24 hours notice to cancel an appointment will be charged our full current fee for that appointment.

Late Arrivals: May be accommodated if the schedule allows; otherwise, you will be charged our full current fee for that appointment.

Missed appointments fees are not covered by insurance or OHIP.

PAYMENT POLICY:

Payment is due at the end of every appointment.

Please Note: Clients must keep track of their own insurance coverage limits and are responsible for any charges not covered by insurance. Telma Grant P.T is not responsible for tracking coverage limits.

By indicating and signing below, I hereby authorize Telma Grant, P.T to release reports and/or all or part of my (or my child's) physiotherapy patient record to the following:
My Family Physician
My Specialist
Other
Date (yyyy/mm/dd)

YearMonthDay
Date
Signature of Patient/Guardian

Clear
By signing this document, you are confirming that all information is correct and that you have read and understood our clinic's cancellation and payment policies.
Name

FIRST NAMELAST NAME
DATE OF BIRTH (yyyy/mm/dd)

YearMonthDay
Date
MEDICAL CONTRAINDICATIONS AND HISTORY: IF PATIENT APPLIES TO ANY MEDICAL CONDITION BELOW, PATIENT IS UNABLE TO HAVE ANY OF THE FOLLOWING MODALITIES: TENS/ULTRASOUND
ELECTRONIC IMPLANT/PACEMAKER:(No tens/IFC or shockwave)

YesNo
OPEN WOUNDS, RASHES OR ECZEMA OR PSORIASIS:(no treatment over affected area)

YesNo
SEIZURE/EPILEPSY: (no tens/IFC)

YesNo
CANCER/SKIN CANCER: (ACTIVE TREATMENTS OR WITHIN 3MONTHS) (No tens/IFC, klaser, shockwave, acu)

YesNo
PREGNANCY OR SUSPECTED:(no modalities)

YesNo
BLOOD CLOTS? (DVT) (no treatment over affected area)

YesNo
If yes to blood clots, WHERE?
IMPAIRED: CIRCULATION/SENSATION

YesNo
IMPAIRED: COGNITION (no modalities)

YesNo
DIABETES: (Treatment can affect blood sugar levels)

YesNo
RECENT OR SUDDEN WEIGHT LOSS/GAIN

YesNo
Do You Smoke?

YesNo
Do you exercise regularly?

YesNo
HEART: Check all that apply

Heart PalpitationsAngina (Chest Pain)Abnormal Heart Rate: HighAbnormal Heart Rate: LowBlood Pressure
LUNG: Check all that apply

AsthmaEmphysemaShortness of BreathChronic Lung Problem
ALLERGIES: Check all that apply

Skin TapeBand AidLatexUltrasound GelOther
Do You Have Any Recent Fractures (Last 3 Months)
Have You Had Any Recent Surgeries (Last 3 Months)
Do You Have Any Total Joint Replacements (Knee, Shoulder, Hip):(No Ultrasound over affected area, Tens is fine if intact sensation)
Check all that apply

Abnormal BleedingArthritisDizzinessHard of HearingBowel/Bladder ProblemsOsteoporosisThyroid Problem (hyper or hypo)Auto Immune DisorderHepatitis or HIV (No acu)
MEDICATIONS: PLEASE CHECK IF YOU ARE TAKING ANY OF THE FOLLOWING:

Anticoagulants (blood thinners)Pain PatchOxycontinMuscle RelaxantsBlood Pressure MedicationsMorphinePercocetHeart MedicationDiabetes Medication(insulin)Anti-inflammatoriesSteroids (Cortisone)
Other
Are you on any medications to help treat the current condition, if so, do they help?

YesNo

Fall Checklist

	Yes	No
Experiences dizziness/vertigo with the change of position?
Have you had any falls in the past 12 months?
Do you have a problem with your memory?

If you had any falls in the past 12 months, how many times?
CREDIT CARD AUTHORIZATION & INSURANCE INFORMATION
You do not have to complete this section if:

You pay Telma Grant, P.T. for services rendered after each visit.

All Direct Billing patients are required to provide a valid credit card to keep on file. If your insurance does NOT pay 100% of the submitted fee, any outstanding balance will be charged to your credit card we have on file.

In the event of a missed cancelled appointment with less than 24 hours' notice, your card will be automatically charged our full current fee for that appointment.

Credit Card Authorization:

In the event of a missed or cancelled appointment with less than 24 hours' notice, your card will automatically be charged our full current fee for that appointment.
Card Type

VisaMasterCardVisa DebitAmerican Express
Cardholder Name (*as shown on card):
First 4 numbers on card
Middle numbers on card
Last 4 numbers on card
Expiration Date (mm/yy)
CVC
By signing below, I hereby authorize Telma Grant, P.T. to charge my credit card above for any outstanding amounts owing on my account. I understand that my information will be securely saved on file for future transactions on my account. I further understand that I may cancel this authorization with two (2) weeks' notice by contacting Telma Grant, P.T. in writing at the address below. This authorization will remain in effect until it is cancelled.
By checking this box, I opt out of providing my credit card information and will be paying any outstanding fees onsite at Telma Grant, Physiotherapy.

Please check
Cardholder's Name (please print):
Cardholder's Signature

Clear
Patient Signature

Clear
IF OBTAINING SERVICES VIA INSURANCE COVERAGE, PLEASE COMPLETE THE FOLLOWING
Extended Health Carrier #1: Name of Insurance Company
Name of Insured (First & Last Name)
Date of Birth of Insured (yyyy/mm/dd)

YearMonthDay
Date
Policy Number
Group Number
Identification Number
Extended Health Carrier #2: Name of Insurance Company
Name of Insured (First & Last Name)
Date of Birth of Insured (yyyy/mm/dd)

YearMonthDay
Date
Policy Number
Group Number
Identification Number
Should be Empty:

Private Patient: No Direct Billing

HEALTH INTAKE AND HEALTH QUESTIONNAIRE

CREDIT CARD AUTHORIZATION & INSURANCE INFORMATION

IF OBTAINING SERVICES VIA INSURANCE COVERAGE, PLEASE COMPLETE THE FOLLOWING