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INFORMED CONSENT FORM

FORM #:  1021

PATIENT INFORMATION

Patient ID: _________________

Your Last NameYour Last Name
Your First NameYour First Name
Your Date of BirthYour date of birth
Gender
Your Address (Street & number)Street and number
Your City
Postal Code
Home Phoneyour home phone
Work Phoneyour work phone
Cell Phonefor phone & text reminders

Physiomobility Health Group staff may leave phone messages at provided numbers for confirmation or changes to your scheduled appointments.  (Please check the phone numbers below if you do not want us to leave phone messages)

By providing your email, you are consenting to email communication from Physiomobility Health Group such as appointment reminders, statements, invoices, exercise instructions, newsletters & commercial electronic messages.
Do not leave phone messages on these phone numbers:Chcek those that apply
EMERGENCY CONTACT INFORMATION
Emergency contact’s Last NameEmergency contact’s Last name
Emergency contact’s First NameEmergency contact’s First name
RelationshipRelationship to your emergency contact
Emergency contact’s Phone No.Emergency contact’s Phone no.
FAMILY PHYSICIAN INFORMATION
Physician's Full Namefamily physicians full name
Physician's Phone No.family physicians phone no.
REFERRAL INFORMATION
Referring physicianCheck this if your are referred by your Family physician above
Referring Physician's NameReferring physicians full name
Referring Physician's PhoneReferring physicians phone no.
Referred by:Check those that apply, or write in Others field here to the right :
Others (Please specify)Please specify

If you are referred by Family, Friend or a Patient, who should we thank:

Name of the friend, family or Patient
INFORMATION ON YOUR VISIT
Primary reason for your visit
0 /

The health information requested on the following form will assist us in treating you safely. If you have any questions about the requested information, please feel free to ask.

Do you currently have or have you previously had any of the following conditions?

For Cancer, Hear disease and other conditions not listed above, please provide more information

Please provide more information here
0 / 300
For Women only
Are you currently pregnant?
If pregnant, how many weeks ?Please specify
Do you currently (or within the past year) have any of the following symptoms?
Do you have ?

Please tell us what your primary goals are or what you wish to achieve at Physiomobility?

Primary goals of your visit
0 /
CANCELLATION or NO SHOW POLICY

We, at Physiomobility are here to provide you with the very best care and attention. We understand that unforeseen events and emergencies occur in everyone’s lives. Out of respect for both your practitioners and your fellow patients we ask that you do your very best to arrive on time and to notify us as early as possible in the event that you are unable to attend. Last minute cancellations and no-shows affect our ability to provide an outstanding experience to all of our patients.


In consideration for our therapists’ time, we have adopted the following policy:


We require a minimum of 24 hours’ notice for change or cancellation of any appointment. This will allow us to fill the available time slot with another patient who needs our services. A full amount of the service fee will be charged for late cancellation/no show if you cancel the same day or if you do not show up for your appointment. Please note that this fee is not billable to insurance policy and remains your responsibility.

SIGN & SUBMIT

Electronic Signature 

Please write Patient/Guardian full name below which serves as electronic signature.

Patient/ Guardian nameyour full name
Dateof appointment
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physiomobility_healthgroup-logo-2021

WE ARE OPEN

AS ESSENTIAL HEALTHCARE PROVIDERS, WE REMAIN OPEN FOR IN-CLINIC TREATMENTS DURING THE PROVINCE WIDE EMERGENCY BREAK ANNOUNCED ON APRIL 01, 2021

Physiomobility continues to remain open and is not part of the lockdown. We continue to have rigorous disinfection policies and procedures in place to ensure the safety of our community and are open for patient in-person visits with all of our practitioners.

Virtual appointments are available and encouraged for those who are at a heightened risk of illness.

We remain focused on our quality of care & our continued commitment to helping our patients feel their best. For further assistance, you can contact us at 416-444-4800 during our opening hours. 

The Physiomobility Team