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Forms – General Intake Form

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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
Your Address (Street & number)Street and number
Your City
ProvinceClick to pick a province
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
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 /
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
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