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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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. 2