lvphysio_Patient_Intake

Patient Intake Form
First Name
Last Name
Date of Birth

DayMonthYear
Date
Preferred Name
Preferred Pronouns
Address

Address

Street Address Line 2

CityState / Province

Postal Code
Phone (Cell)
Phone (Home)
Phone (Work)
Email
example@example.com
Family Doctor (Name, Phone Number, Address)
Type a Emergency Contact (Name, Phone number, Relation to you)
Communication Preferences
By default, all clients receive email and text reminders for appointments. If you prefer not to receive these reminders, please notify our reception team.

Yes! I’d love to receive appointment reminders, exercise plans and other relevant updates by email! (Your email will never be shared at any time)
How did you hear about us?
How did you hear about us?

I am a Previous PatientGoogle Search/WebsiteFriend or Family ReferralFamily DoctorAdvertisement:Drove By/Outdoor SignSocial Media (Facebook/Instagram)Other Healthcare ProviderOther
Friend or Family Referral
Advertisement
Other Healthcare Provider
LV Physiotherapy Policies:
1. Please provide 24 hours notice of cancellation for your appointment. A fee will be charged to your account if you do not show up for your appointment or if you choose to cancel within 24 hours of your appointment time (See Full Cancellation and Missed Appointment Policy)

2. Payments for services are the responsibility of the patient and are to be paid at each visit via cash, debit, or credit card. If a third party payer (EHB, WSIB, MVA) denies or partially pays the amount billed, you are responsible for paying the outstanding amount.

I understand, and agree to, the criteria listed under LV Physiotherapy policies
Signature of Patient or Legal Guardian

Clear
Date

MonthDayYear
Date
Cancellation and Missed Appointment Policy
At LV Physiotherapy, we aim to provide high quality care and value all of our patients at the clinic. We thank you for trusting us and we will continue to work hard to make sure you are satisfied with your care and reach your rehab & life goals!

We will provide you with appointment reminders (via email and/or text) in addition to providing you a list of your future appointments at your request.

In order to be respectful of other patients and our therapists, we require you to CALL US a minimum of 24 hours prior to your appointment if you need to cancel or reschedule your appointment. Otherwise, a $35 fee will be charged as per our policy below.

1. First Cancellation/No Show WITHIN 24 hours of your appointment
a. A warning will be given

2. Second Cancellation/No Show WITHIN 24 hours of your appointment
a. $35 fee will be charged

3. We require a Payment Method on File for all Patient Bookings.

However, we know sometimes life happens and schedules may change. Serious emergencies or circumstances will be considered.

By signing below, I confirm I have read and understand the policy above.
Name
Date

MonthDayYear
Date
Signature

Clear
Health History Form
An accurate health history is important to ensure that it is safe for you to receive therapy. If your health status changes in the future, please let us know. All information gathered is confidential except as required or allowed by law.
Purpose for your Visit:
Primary Complaint
Date of Onset

MonthDayYear
Date
Has this happened before? If so, when
Previous treatment received for this complaint
Imaging for this complaint (e.g., X-Ray, Ultrasound, MRI):
Past Medical History:
CARDIOVASCULAR

High blood pressureLow blood pressureCongestive heart DiseaseHeart attackChest painPhlebitis/varicose veinsHeart diseasePacemaker or similar
RESPIRATORY

Chronic coughShortness of breathBronchitisAsthmaEmphysema
NEUROLOGICAL

Stroke/CVASpinal Cord InjuryMultiple SclerosisParkinson’s DiseaseOther
HEAD/NECK

History of headaches/migrainesNew onset headaches/migrainesVision loss/changesDizziness/Double visionHearing loss/ear condition(s)
PELVIC HEALTH

Pregnant
Due Date

MonthDayYear
Date
# of prior pregnancies
COMMUNICABLE DISEASES

HepatitisSkin conditionsTBHIV/AIDSAny other communicable diseasesor haemophilia?
If so, please describe:
OTHER CONDITIONS

Osteoporosis/OsteopeniaFracturesArthritisDiabetes Onset/typeEpilepsyAnxiety/DepressionCancerAllergies/hypersensitivityDigestive ConditionsOrgan dysfunctionLoss of sensationVertigoUrinary/bowel incontinenceOther
Fractures: indicate
Arthritis - Onset/type:
Diabetes Onset/type:
Cancer - Onset/type/currentstate:
Loss of sensation (Area:
SURGERY: Please list any previous surgical procedures and any details/hardware (i.e., prosthesis, wires, internal pins, fixators):

0/40
Is there a Family History of any ofthe above conditions? if so, pleasedescribe:

0/100
Current Medications:
Please list.

0/100
Consent for Assessment and Treatment
Assessment and treatment at LV Physiotherapy may include, but are not limited to: manual therapy, massage therapy, acupuncture, electrotherapy, therapeutic exercise, functional and cognitive assessments, balance and mobility training, home and workplace safety recommendations, communication and swallowing therapy, and patient/caregiver education.

It is our policy to ensure that patients are informed of the benefits, potential risks, side effects, alternatives, and consequences of not proceeding with treatment before any intervention begins. If you have questions or concerns, please inform your healthcare provider so they can explain or adjust your program. If at any time you choose not to participate in a treatment, you must inform your provider.

I understand and agree with the above criteria and, in compliance with the Health Care Consent Act, 1996, voluntarily consent to participate in assessment and treatment for my condition(s) at LV Physiotherapy.

I understand that I may withdraw my consent at any time by informing my healthcare provider, and that I may request to stop or change treatment at any point.
Patient Name or Legal Guardian (print)
Date of birth

DayMonthYear
Date
Signature of Patient or Legal Guardian

Clear
Date

MonthDayYear
Date
Comments
Release of Medical Information
Your privacy is important to us. All information provided will be kept confidential unless required by law. With your written permission, LV Physiotherapy may release or obtain relevant health records from other practitioners or agencies involved in your care, or as noted below.
Signature of Patient or Legal Guardian

Clear
Date

MonthDayYear
Date
Comments
Should be Empty:

Patient Intake Form

Communication Preferences

How did you hear about us?

LV Physiotherapy Policies:

Cancellation and Missed Appointment Policy

Health History Form

Purpose for your Visit:

Past Medical History:

Current Medications:

Consent for Assessment and Treatment

Release of Medical Information