Download physiotherapy client intake and consent form

 PHYSIOTHERAPY CLIENT INTAKE AND CONSENT FORM Date:
Name:
Birth date (D/M/Y):
Address:
Primary Phone:
City/Province
Alternate Phone:
Postal Code
Email address:
Emergency Contact: (Name/Phone)
Family Doctor: (Name/Phone)
How did you hear about us?______________________________________________________
PRIMARY CONCERN(S): (Area of the body, type of pain (sharp, dull, burning..), duration of
symptoms)
Symptom Intensity: (Please mark on the line)
______________________________________________________________
(0) No pain
(10) Worst pain
PREGNANT? ______ NO ______YES ________ # weeks,
Primary Practitioner: _______ Family Doctor/________Midwife/________ OB/GYN
MEDICAL HISTORY:
Current conditions:
Previous conditions, surgeries:
Current Medications:
1 Physiotherapy Clinic Privacy Policies. All information contained within your file is handled as
strictly personal. Only under written consent or as required by law will this information be shared
externally. Should you have questions about our privacy policy; or if you would like a written version,
please feel free to ask. Please note that by providing your consent below, it is assumed that any
concerns or questions you have, have been addressed to your satisfaction and that you choose to
proceed.
Appointment. Appointment frequency and expected duration should be discussed with the
Physiotherapist and scheduled accordingly with the receptionist or online. Please check in at
reception each visit. It is important that you arrive a few minutes before each treatment time, in order
to prepare. If you do arrive late, you will be seen for the remainder of your scheduled time.
Cancellation, Lateness and No-shows. Any appointment cancelled on the same day, or no-shows,
will be charged the full service fee (which may not be covered by your extended Health Care Plan).
This is necessary to ensure proper respect for treatment times and the difficulty in rescheduling with
less than 24 hours notice.
It is very important that you clarify your coverage prior to initiating physiotherapy treatment to
ensure you are reimbursed to your full expectation. Clients are responsible for full payment of
their account at the end of treatment. Payment can be made by cash, debit, Visa and Mastercard.
Treatment Fees
Orthopaedic Physiotherapy
Pelvic Health Physiotherapy
Initial assessment and re-evaluations (60 mins): $124
Follow-up visit (60 mins): $129
Follow-up visit (45 mins): $98
Follow-up visit (30 mins): $67
Initial assessment (60 mins): $124
Pelvic Health Follow-up (45 mins): $98
Missed appointment/late cancellation fee: $65
Cardiac Pacemaker, Medical Conditions. Clients with cardiac pacemakers, or other medical
conditions should notify their therapist prior to the initial assessment.
I fully understand and agree to abide by the above policies as outlined.
Name________________________
Signature______________________________ __________ Date____________
Consent to assessment and treatment. I___________________________________ consent to the
assessment and treatment that my physiotherapist will provide. I understand that my physiotherapist
will review the risks, benefits and rationale for the treatments provided on an ongoing basis and that
consent will be reviewed as treatment changes or progresses. I understand that my consent to all or
part of my treatment can be withdrawn at any time.
Signature_______________________________________________________Date___________
* This file will contain only the record of your physical therapy assessments and treatments.
* Should you require a copy of your file, a list of commonly used abbreviations can be provided.
* Health Information Custodian (HIC) of this file is: Angela Growse, PT.
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