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 is 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 am going to 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 am 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 are 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 does 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 is 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 think may interest you.