Tuxedo_PT_Patient_Information

Patient Information

Physiotherapy
Last Name
First Name
Initial
Date of Birth

DayMonthYear
Date
Identifying Gender
Address (#, Street Name)
City/Prov
Postal Code
Cell Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Ext
Email Address
example@example.com
Preferred method of contact:

TextPhoneEmail
Who referred you?
Occupation
Employer
Emergency Contact
Relationship
Phone Number
Please enter a valid phone number.
Consent for Assessment and Treatment

I understand that my physiotherapist is providing physiotherapy services within their scope of practice. I understand that my physiotherapist will collaborate with me making decisions regarding assessment and treatment. I acknowledge that with any treatment there can be risks, those risks have been explained to me and I assume such responsibility as well as potential for forgoing the suggested care. I should discuss any questions about my treatment and rehabilitation with my physiotherapist.
I agree
Cancellation/No Show Policy

Your appointment time is reserved for you. We require 24 hours' notice for any cancellations. Patients who provide less than 24 hours' notice will be charged a $35 cancellation fee. Patients who do not cancel and do not show up for their appointment will be charged a $45 no show fee.
I am aware of the Cancellation/No Show Policy
Physiotherapy Fees and Services

Payment for services are the responsibility of the patient and are to be paid for at each visit. If a third party payor (i.e. WCB, MPI) denies my claim and/or refuses to pay for the full amount billed, I am responsible for paying the outstanding amount. I understand that I am responsible for any reimbursement provided by any other private insurance companies such as Blue Cross, Great West Life, etc.
I agree
Consent for Communication/Release of Information

I authorize the clinic and its associated health professionals to communicate with my doctor, massage therapist, dentist, chiropractor, naturopathic doctor or others deemed as necessary for my beneficial treatment. I also understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission.
I agreeI do not want my information shared with my other health care practitioners.
Email Communication

Effective July 1, 2014, Canada's new anti-spam legislation requires us to secure your consent so that we can communicate with you electronically.
We would like your permission to send you the following:

Email reminders of upcoming appointmentsInstructions and videos regarding prescribed exercises and updates regarding the same.Notifications regarding upcoming classes/workshops/services.
Name of Patient
Name of Guardian (if applicable)
Signature

Clear
Date

MonthDayYear
Date
Please complete this section if you have a third-party insurer:
Name of Insurer
Contract Policy #:
Name of subscriber (if not yourself)
ID #
Please complete this section if your treatments are as a result of Worker’s Compensation or Autopac Claim:
WCB/MPIC Claim No:
Adjudicator/Adjuster’s Name:
If this is an MPIC claim, please specify the location of your claims center:
MPIC Injury Claim No:
If this is a WCB claim, please complete the following:
Employer:
Address:
To expedite the processing of your claim, please ensure that all forms have been completed by your employer and yourself and forwarded to WCB.
Referring Doctor/Professional:
Address:
Phone Number
Please enter a valid phone number.
Family Doctor (if different from above):
Address:
Phone Number
Please enter a valid phone number.
List any other health care providers that are involved in your care for injury (name and contact information)
Please list any surgeries, X-Rays, MRI’s, CT Scans or Bone Scans:
Please list any hospital stays and reason:
Please list current medications:
Have you taken any Advil or Tylenol in the last 48 hours?

YesNo
Presence of

PacemakerArtificial JointsInternal Wires/Pins
Primary Pain/Injury Area
0 - no pain12345 - moderate pain678910 - unbearable pain
Secondary Pain Area
0 - no pain12345 - moderate pain678910 - unbearable pain
Should be Empty:

Patient Information