russettrehab_Orthotic

RUSSETT REHABILITATION AND WELLNESS CLINIC

26 Thames Road E., ON, NOM 1X0
PATIENT INFORATION - ORTHOTICS
*$200 deposit is required in order for Orthotics to be made*
First Name
Initial
Last Name
Date

MonthDayYear
Date
Birth date

MonthDayYear
Date
Home Address
City
Province
Postal Code
Phone #
Other Contact #
Please enter a valid phone number.
Height
Weight
Foot Size
Occupation
How Long (Years)
Extended Health Care Insurance

YesNo
Extended Health Care Company
Medial Doctor
Phone #
Address
Acceptance as Patient:

I understand and agree that the practitioners of Russett Rehabilitation and Wellness Clinic have the right to refuse or accept me as a patient at any time before treatment begins. The taking of a history and the conducting of a physical examination are not considered treatment, but are part of the process of information gathering SO that the doctor can determine whether to accept as a patient.
Signature

Clear
Date

MonthDayYear
Date

If you answer yes to any of the following questions please provide details: