FORM #: 1021
Patient ID: _________________
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)
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.
For Cancer, Hear disease and other conditions not listed above, please provide more information
For Women only
Please tell us what your primary goals are or what you wish to achieve at Physiomobility?
It is Physiomobility’s policy that payment for services is due in full by Cash, Debit or Credit Card or direct payment by insurance at the end of each treatment session. We require a minimum of 24 hours’ notice for change or cancellation of any appointment.
Your account will be charged the full treatment fee if you cancel with less than 24 hours’ notice or if you do not show up for your appointment.
Should you arrive late for your appointment or request to leave early, the full fee for the appointment time you have booked will also apply. Please Note: We understand that your time is valuable and therefore make every effort to keep our schedule running on time. Due to the nature of our work, unexpected delays sometimes occur. Please be assured that under these circumstances you will still receive your full treatment time.
Please write Patient/Guardian full name below which serves as electronic signature.