1(905) 945 - 7771 [email protected]

PATIENT INTAKE FORM

    Name *

    Date of Birth (DD/MM/YYYY)

    Address Line 1

    Address Line 2

    City

    Postal Code

    Home Phone

    Work phone

    Do you have Health Care Benefits ?YesNo

    Name of medical Insurance Company

    Policy/Plan number

    I.D. / Cert. Number

    Be sure to know your percent coverage and maximum allotment for
    physiotherapy

    Are you covered under a second Insurance Benefit Plan?
    YesNo

    Name of medical Insurance Company

    Policy/Plan number

    I.D. / Cert. Number

    Are you here as a result of a Motor Vehicle Accident?
    YesNo

    (IF YES)Name of Automobile Insurance Company

    Insurance Adjuster

    Phone

    Claim number

    Date of Accident (DD/MM/YYYY)

    Are you here as a result of a Work Injury(WSIB)?
    YesNo

    (IF YES)Name of WSIB contact name

    Employer

    Phone

    Claim number

    Date of Accident (DD/MM/YYYY)

    How did you find out about Progressive Physiotherapy?

    GoodLife memberDoctorYellow PagesCo-workerInternetFriendOther

    Signature*

    E-mail*

    Date (DD/MM/YYYY)

    Patient Authorization

    Patient Name

    Date of Birth (DD/MM/YYYY)

    Release of Information & Consent for Treatment

    All information provided herein is true and correct.

    I wish to receive treatment at Progressive Physiotherapy Clinic. I permit
    its employees and all other persons caring for me to treat me in ways they
    judge are beneficial to me.I consent to rehabilitation and related
    services at Facility. I understand, acknowledge and affirm that such
    rehabilitation and related services may involve bodily contact, touching
    and/or direct contact of a sensitive nature. I understand that this care
    can include an evaluation, testing and treatment. No guarantees have been
    made to me about the outcome of this care.

    I give permission to Progressive Physiotherapy Clinic to release
    information, verbal and written, contained in my medical record, and other
    related information, to my insurance company, rehab nurse, case manager,
    attorney, employer, school, related healthcare provider, assignees and/or
    beneficiaries and all other related persons as it relates to my treatment
    and/or payment for services provided.

    I authorize Progressive Physiotherapy Clinic to obtain medical records
    and/or professional information from my physician or other medical
    professional as it relates to my treatment.

    The signature below certifies that I have read and understand the above
    information

    Initial*

    Assignment of Benefits

    I authorize payment directly to Progressive Physiotherapy Clinic for
    services and to bill and release payment directly to Progressive
    Physiotherapy Clinic

    This is a direct assignment of my rights and benefits under this policy.
    A photocopy of this assignment shall be considered as effective and
    valid as the original.

    Initial*

    Notice of Privacy Practices (HIPAA Acknowledgement/Consent)

    I hereby acknowledge that I have received a copy of The Notice of
    Privacy Practices for Progressive Physiotherapy Clinic, its
    subsidiaries, and/or affiliates.

    In addition, I hereby consent to the use and disclosure of my personal
    health information for the purpose of treatment, payment, and health
    care operations.

    Initial*

    Payment Guarantee

    I agree to pay Progressive Physiotherapy Clinic for the services provided
    to me or the party named above. If any such law, such as worker's
    compensation, or insurance contract prohibits payment for these services,
    i will cooperate and assist in the provision of information,
    authorizations, releases, or any other type of information necessary to
    allow for speedy collection from my third-party payer. Where the law or an
    insurance contract does not prohibit payment by me, I acknowledge
    responsibility for any and all account balances.

    The Intake & Verification of Benefits Form is only an explanation of
    coverage obtained from my insurance company and it is not a guarantee of
    coverage.If the information provided by my insurance company is not
    accurate or the insurance company changes its coverage, I will be
    responsible for payments for services. I understand that my good-faith
    payment may not be inclusive of all payments for which I am responsible
    and I may be billed for any remaining balance.

    I further understand that this agreement is binding regardless of any
    legal transaction currently in progress or initiated during or after the
    course of my treatments unless agrees to in writing by myself and a
    representative of Progressive Physiotherapy Clinic.

    Initial*

    Patient Information & Data Sheet

    I hereby acknowledge that the information I provided on the Intake Form
    and the Patient Data Sheet is correct

    Initial*

    Patient or Guardian Signature*

    Date (DD/MM/YYYY)

    Medical History Questionnaire

    Patient Name

    Date of Birth (DD/MM/YYYY)

    Age

    Reason for Therapy

    Date of Injury or Onset (DD/MM/YYYY)

    Is the Reason for Therapy Accident Related?YesNo

    IF Yes please check one

    AccidentAutoWorkOther

    If other please explain:

    Are you currently receiving any other care for the condition mentioned
    above? YesNo

    If yes, please list:

    Have you ever received therapy in the past for the condition mentioned
    above?YesNo

    If yes, when?

    Previous Treatment Received

    Previous Treatment SuccessfulUnsuccessful

    Have you received therapy services for other problems/conditions during
    this calendar year?YesNo

    If Yes, please list

    Could you be pregnant? YesNo

    Do you now have or have you ever had any of the following
    conditions?

    ArthritisYesNo

    OsteoporosisYesNo

    High Blood Pressure YesNo

    Heart Disease / Heart Attack YesNo

    Pacemaker YesNo

    Stroke YesNo

    Vascular disease YesNo

    Hypersensitivity to Heat/Cold YesNo

    Asthma YesNo

    Shortness of Breath YesNo

    Chronic Cough YesNo

    Dizziness/Light Headed-ness/ Fainting Spells YesNo

    Nausea/Vomiting YesNo

    Diabetes YesNo

    Anemia YesNo

    Swelling in Ankles YesNo

    Deep Vein Thrombosis (DVT) YesNo

    Seizures/Epilepsy YesNo

    Fatigue/Weakness YesNo

    Cancer /Tumor YesNo

    Recent Weight Loss or Gain YesNo

    HIV / AIDS YesNo

    Hepatitis YesNo

    Tuberculosis YesNo

    Recurrent Infection(s) or infection in past 3 months YesNo

    Fever/Chills YesNo

    Numbness/Tingling YesNo

    Thyroid Problems YesNo

    Headaches YesNo

    Head/Injury/Concussion YesNo

    Hernia YesNo

    Kidney/Bladder Problems YesNo

    Previous Fractures YesNo

    Previous Surgeries YesNo

    Metal in body or Surgical Implants YesNo

    Depression YesNo

    Anxiety YesNo

    Smoking YesNo

    Others(Please describe below) YesNo

    If you answered "Yes" on any of the above or have other conditions not
    listed, please explain and give approximate date(s):

    Do you have any allergies? YesNo

    If Yes list allergies

    Are you presently taking any medication? YesNo

    If Yes list medications and specify condition

    At present time, would you say that your health is (select one):

    ExcellentVery GoodFairPoor

    The information is correct to the best of my knowledge.

    Patient/Parent/Guardian Signature *(sign in box below)

    Date (DD/MM/YYYY)

    Notice of Privacy Practices

    THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
    DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

    Uses and Disclosures of Your Health Information

    Treatment.Your health information may be used by staff members or
    disclosed to other health care professionals for the purpose of evaluating
    your health, diagnosing medical conditions, and providing treatment. for
    example, results of evaluations will be available in your medical record
    to all health professionals who may provide treatment or who may be
    consulted by staff members.
    Payment. Your health information may be used to seek payment from
    your health plan, from other sources of coverage such as an automobile
    insurer, or from credit card companies that you may use to pay for
    service, the services provided, and the medical condition being
    treated.
    Health care operations. Your health information may be used as
    necessary to support the day-to-day activities and management of the
    Company. For example, information on the services you received may be used
    to support budgeting and financial reporting, and activities to improve
    quality.
    Law enforcement. Your health information may be disclosed to law
    enforcement agencies, without your permission, to support government
    audits and inspections, to facilitate law-enforcement investigations, and
    to comply with government mandated reporting.
    Public health reporting. Your health information may be disclosed
    to public health agencies as required by law. For example, we are required
    to report certain communicable diseases to the state’s public health
    department.
    Other uses and disclosures require your authorization. Disclosure
    of your health information or its uses for any purpose other than those
    listed above requires your specific written authorization. If you change
    your mind after authorizing a use or disclosure of your information you
    may submit a written revocation of the authorization. However, your
    decision to revoke the authorization will not affect or undo any use or
    disclosure of information that occurred before you notified us of your
    decision.
    Additional Uses of Information
    Appointment reminders. Your health information will be used by our
    staff to send you appointment reminders.
    Information about treatments Your health information may be used to
    send you information on the treatment and management of your medical
    condition or new technology that you may find to be of interest. We may
    also send you information describing other health-related goods and
    services that we believe may interest you