Forms - General Intake Form

GENERAL PATIENT INTAKE 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

MaleFemale

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 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

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)Family/Friend/PatientInternetSocial mediaEventsStaffWork/Live in Shops at Don Mills

Others (Please specify)Please specify

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 /

PAYMENT & CANCELLATION POLICY

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.

SIGN & SUBMIT

Electronic Signature

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

Patient/ Guardian nameyour full name

Dateof appointment