Alliance Physio

Physiotherapy/Chiropractic/Osteopathy Intake Form

107-6750 Winston Churchill Blvd. Mississauga, ON. L5N 4C4. 905-785-9952
Name

FIRST NAMESURNAME
DATE

MonthDayYear
Date
Parent/Guardian Name (under 18 yrs)
Contact Email
example@example.com
Date of Birth

MonthDayYear
Date
Gender
Emergency Contact Name
Emergency Contact Number
HOME ADDRESS
PROVINCE
POSTAL CODE
MOBILE NUMBER
HOME PHONE
OCCUPATION
FAMILY PHYSICIAN NAME
FAMILY PHYSICIAN TELEPHONE
HOW DID YOU HEAR ABOUT US?
PRIVATE INSURANCE INFORMATION (PRIMARY INSURANCE)
Insurance Company
Members Name
Date of Birth of Plan member

MonthDayYear
Date
Plan Number
Date of Birth of Plan member

MonthDayYear
Date
ID Number
PRIVATE INSURANCE INFORMATION (SECONDARY INSURANCE)
Insurance Company
Members Name
Plan Number
ID Number
Motor Vehicle Accident (MVA) Claim
YesNo
Insurance Name
Policy Number
Claim Number
Adjuster Name
Adjuster Phone Number
Date of Accident

MonthDayYear
Date
Personal Health History
The health information requested on the following forms will assist us in treating you safely. If you have any questions about the requested information, please feel free to ask. Your written permission is required to release any information, unless required by law.
Primary reason for your visit:
Describe your general health:
YesNo
Please explain below:
Please rate your pain from a scale of 1-10. 1 being minimal pain.
ShouldersArmsElbowsFeetHipsLegsKneesNeckMid BackSacroiliac JointsPelvisHandsLower backHead
Briefly provide relevant details of the above injury:
Date of Injury:

MonthDayYear
Date
YesNo
If yes, date of car accident

MonthDayYear
Date
YesNo
DATE OF FALL

MonthDayYear
Date
YesNo
DATE OF CONCUSSION

MonthDayYear
Date
YesNo
WHAT TYPE OF SURGICAL PROCEDURE?
DATE OF SURGICAL PROCEDURE

MonthDayYear
Date
YesNo
Please specify
YesNo
IF YES, HOW FAR ALONG ARE YOU?
DO YOU HAVE ANY CURRENT/PAST MEDICAL CONDITIONS?
PLEASE LIST YOUR CURRENT MEDICATION AND SPECIFY REASON FOR TAKING MEDICATION:
DO YOU HAVE ANY ALLERGIES TO MEDICATIONS?
TOBACCO USE: AVERAGE PACKS PER DAY blanks . FORblank YEARS.
AVERAGE NUMBER OF ALCOHOL CONTAINING BEVERAGES PER WEEK:
Dizziness, weakness, faiting, vertigo, drop attacks or disorientation, headaches, migrainesDisturbances of vision, speech, co-ordination or balance, difficulty swallowing, hearing lossNumbness or pins and needles in any part of your body? any loss of sensation?Difficulty with bowel or bladder functionCough, shortness of breath, chest pain, or palpatationsPoor apetite, nausea or vomitingDifficulty sleepingA significant weight change in the past year
HAVE YOU EVER CONSULTED A PHYSICIAN FOR ANY OF THE ABOVE: (If yes please explain)
DIABETESHEART ISEASE/PROBLEMSCANCERHIGH OR LOW BLOOD PRESSURETUMORPOSSIBLE CARDIO INSUFFICIENCYEPILEPSY (TYPE?)STROKE/CVAHEPATITISASTHMAHIV/AIDSMIGRAINESSTD'SHEADACHES (type?)TUBERCULOSISSKIN CONDITIONSINFECTIOUS CONDITIONSALLERGIES/HYPERSENSITVITYGYNECOLOGICAL CONDITIONSARTHRITISPOSSIBLE RESPIRATORY INSUFFIENCIENCY
FAMILY HISTORY: PLEASE IDENTIFY ANY PROBLEMS LISTED ABOVE THAT HAVE OCCURRED IN YOUR IMMEDIATE FAMILY (indicate family members affected)
I understand the above and agree to give consent to the health practitioners for treatment at Alliance Physio. I understand that in order to provide safe treatment, my health practitioner may need to communicate with my physician regarding my condition and treatment. I understand that Alliance Physio practitioners and staff will collect, use and protect my personal information as set out in the clinics privacy policy.
Signature

Clear
Date

MonthDayYear
Date
Alliance Physio Cancellation Policy
We require a minimum of 24 hours notice for change or cancellation of an appointment. This will enable us to fill the time slot you have vacated with another patient in need of our care.

The cancellation fee is equal to the full fee for the appointment time you have booked.

We understand that last minute changes in your schedule are sometimes impossible for you to avoid.

Should you arrive late for your appointment or request to leave early, the full fee for the appointment will be charged.

We will attempt to remind you of your appointment a day in advance, however please note that we provide this service as a courtesy. Please DO NOT rely on these calls to keep track of your appointments. A cancellation fee equal to the full fee for the appointment for you will also apply for missed appointments.

PLEASE NOTE: We understand that your time is valuable and therefore we 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 receive your full treatment.

I understand the above and agree to abide by this policy:
Patient/ Guardian or Parent Signature

Clear
Date

MonthDayYear
Date
Payment Policy and Insurance Coverage
Fees for services or products are covered by most extended health plans. Each plan can vary greatly as to the amount covered per treatment and the yearly maximums covered. As a policy holder, it is your responsibility to contact your insurance company and confirm the exact details of your coverage. Please note that we may do direct billing for certain insurances/plans, but any differences that are not paid it is the responsibility of the patient to pay. All WSIB cases that are approved are billed directly to WSIB and payment will then be received from WSIB. All MVA charges will first be billed towards your private insurance and then the difference will be billed to your car insurance (based on FSCO rules If direct billing is not allowed please note it will be your responsibility to bring the payment to the clinic

Payment is due in full by cash, debit, visa, mastercard at the end of every treatment session if it is not covered by insurance or direct billing is not allowed. A receipt with all the required information will be provided to you, which you can then submit to your insurance company for re-imbursement.

I understand the above and agree to abide by this policy:
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Physiotherapy/Chiropractic/Osteopathy Intake Form

PRIVATE INSURANCE INFORMATION (PRIMARY INSURANCE)

PRIVATE INSURANCE INFORMATION (SECONDARY INSURANCE)

Motor Vehicle Accident (MVA) Claim

Personal Health History

Alliance Physio Cancellation Policy

Payment Policy and Insurance Coverage