FORM #: 1028
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)
Date of Accident (DD/MM/YY):
Please write Patient/Guardian full name below which serves as electronic signature.
AS ESSENTIAL HEALTHCARE PROVIDERS, WE REMAIN OPEN FOR IN-CLINIC TREATMENTS DURING THE PROVINCE WIDE LOCKDOWN & STATE OF EMERGENCY
Read our COVID-19 Health & Safety Standards and Procedures