Maplecare_Wellington_New

NEW PATIENT FORM
Treatment Location*
PATIENT INFORMATION
Patient's Full Name
Date of Birth

MonthDayYear
Date
Address

Address

Street Address Line 2

CityProvince

Postal Code
Gender

MaleFemale
Email
Please do not use work email address. By providing your email, you are consenting to email communication from MapleCare such as appointment reminders, statements, invoices, exercise instructions, newsletters & promotional messages. If you wish not to receive them, please inform us.
Telephone (H)
Telephone (W)
Cell #
MapleCare staff may leave phone messages at provided numbers for confirmation or changes to your scheduled appointments.

How did you hear about us?

	Check	Specify
Google, online ads, website
Facebook/Instagram
Street sign
Flyer
Newspaper
Referred by friend or family
Referred by Dr
Others

EMERGENCY CONTACT
Full Name
Relationship
Telephone
CARE PROVIDER INFORMATION
Family Doctor's Name
Telephone
Referring Doctor's Name
Telephone
INFORMED CONSENT (Please read completely)
- I authorize MapleCare Physiotherapy to disclose my billing and health information to my insurance provider for the purpose of processing insurance claims on my behalf, and in the event of an audit by the insurance company.
- MapleCare Physiotherapy Clinic is my health information custodian.
- I give consent to the physiotherapists at MapleCare Physiotherapy Clinic for assessing and treating my condition(s) who may use techniques that require them to place their hands on my body.
- I understand that in order to provide safe treatment, my physiotherapist may need to communicate with my physician and/or other health care professionals regarding my condition and treatment, for which I give consent.
- A minimum of 24-hour notice is required for cancelling an appointment to accommodate other patients in need of care. I am subjected to a fee of $50.00 for no-show or cancellations made in less than 24 hours.
- Payment is due in full by cash, debit, credit or cheque for every visit. A receipt with all the required information will be provided.
Please write Patient/Guardian Full Name below which serves as electronic signature:
NAME (Patient/Guardian)
DATE

MonthDayYear
Date
Patient's Full Name
Date of Birth

MonthDayYear
Date
CHIEF COMPLAINT
My chief complaint is
How long have you been dealing with this pain/complaint?
2nd complaint:
3rd complaint:
Please choose the scale below to indicate your *CURRENT* level of pain:

No Pain012345678910As painful as it gets
PAST MEDICAL HISTORY FORM
Please select any of these conditions that you may have had in the past

HypertensionHeart AttackAtherosclerotic DiseaseRheumatic Heart DiseasePacemaker or any other electrical implantsAsthmaEmphysemaShortness of BreathOsteoporosisRheumatoid ArthritisEpilepsy or seizuresGoutFibromyalgiaDiabetesImpaired wound healingHearing LossPoor EyesightFaintingCancerAllergies to adhesives or metalPregnancyHepatitis B, C, HIV, or any other infectious diseasesOther
EXERCISE LEVEL

None1-2x week3-4x week>5x week
WORK ACTIVITY

SittingStandingLight labourHeavy labour
STRESS LEVEL

LowMediumHigh
What types of exercise do you perform?
Do you have fear of needles?

YesNo
Are you taking any anticoagulants (i.e. Aspirin, blood thinners)?

YesNo
Are you taking any antibiotics for an infection?

YesNo
List all medications you are currently taking:
List all surgeries you have had:
Have you had any auto accidents?

YesNo
If yes, please list the injured body part(s) and date of accident:
Are you receiving any treatment from other healthcare professionals?

YesNo
If yes, where:
Have you had any physiotherapy treatment or massage therapy before?

YesNo
If yes, where:
Please write Patient/Guardian Full Name below which serves as electronic signature:
NAME (Patient/Guardian)
DATE

MonthDayYear
Date
Patient's Full Name
Date of Birth

MonthDayYear
Date
PAIN AND SYMPTOMS STATUS REPORT

Please write the location of pain in the body and select the severity level of the pain that the patient is experiencing:

	Location of Pain	Severity Level
Ache
Burning
Numbness
Stabbing
Pins & Needles
Other

Other
(For Motor Vehicle Accidents patients only)
Type of Photo ID
Verified by
Date

MonthDayYear
Date
Date of Accident

MonthDayYear
Date
Do you have any private healthcare coverage?

YesNo
Name of Insurance Company
Motor Vehicle Billing Insurance
Policy Number
Claim Number
Insurance Adjuster Name
Phone
Fax
It is necessary to have all insurance information filled in correctly. Any misinformation may result in invoices being forwarded to the client.
INFORMED CONSENT (Please read completely)
- I authorize MapleCare Physiotherapy to disclose my billing and health information to my insurance provider for the purpose of processing insurance claims on my behalf, and in the event of an audit by the insurance company.
- If not approved for funding through an MVA protocol, I understand that I am responsible for any fees incurred and any treatment fees that are NOT
  covered by my insurance company. Accounts that are 6 months old will be sent to our collections agency. For fee details, please see our front desk staff for more information.
- I am aware of the 24-hour notice requirement to cancel an appointment. I understand that if I fail to attend an appointment or cancel in less than 24 hours, a fee of $50 will be applied to my account which cannot be billed to my insurance coverage.
- I am providing valid credit card information below and authorization for use in case payment of account is required by myself:
Credit Card Type:

MasterCardVisaAMEXOther
1st 8 digits of card
2nd 8 digits of card
Expiry Date (mm/yy)
Please write Patient/Guardian Full Name below which serves as electronic signature:
NAME (Patient/Guardian)
DATE

MonthDayYear
Date
Should be Empty:

NEW PATIENT FORM

PATIENT INFORMATION

EMERGENCY CONTACT

CARE PROVIDER INFORMATION

INFORMED CONSENT (Please read completely)

CHIEF COMPLAINT

PAST MEDICAL HISTORY FORM

PAIN AND SYMPTOMS STATUS REPORT

INFORMED CONSENT (Please read completely)