Forms – General Intake Form

INFORMED CONSENT FORM

PATIENT INFORMATION

General Intake Form – Patient ID: ________________________

Your Last NameYour Last Name

Your First NameYour First Name

Your Date of BirthYour date of birth

Gender

MaleFemaleNon-BinaryDecline to answer

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)

Your Email Addressvalid email

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

Home PhoneWork PhoneCell Phone

EMERGENCY CONTACT INFORMATION

Emergency contact’s First NameEmergency contact’s First name

Emergency contact’s Last NameEmergency contact’s Last 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

Same as 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 :

Doctor (check only if you have been referred to Physiomobility by your doctor)InternetSocial mediaEventsStaffWork/Live in Shops at Don MillsOthers

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.

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?

YesNo

If pregnant, how many weeks ?Please specify

Do you have ?

Metal ImplantPacemaker

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.

For your information, our payment processing system saves an encrypted version of the credit or debit card ,similar to the practice of many other clinics. This information is stored on the merchant processing system, not within our system. Only the last 4 digits of the card are visible to our staff. We do reserve the right to keep a credit card on file for the purpose of charging balances, no show fees or late cancellation fees.

SIGN & SUBMIT

Electronic Signature

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

Patient/ Guardian nameyour full name

Dateof appointment