1(905) 945 - 7771 ppcphysio@gmail.com

PATIENT INTAKE FORM

Name *

Date of Birth

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


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


How did you find out about Progressive Physiotherapy?
GoodLife memberDoctorYellow PagesCo-workerInternetFriendOther

Signature*
E-mail*

Date



Patient Authorization

Patient Name

Date of Birth

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


Medical History Questionnaire

Patient Name

Date of Birth
Age

Reason for Therapy

Date of Injury or Onset

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


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