Patient Intake FormPlease feel free to complete our Patient Intake Form below before your first visit or if you are doing distance therapy. General InformationName* First Last Guardian (if under 18)GenderAddress* Street Address Address Line 2 City Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Date Of Birth* MM DD YYYY Home Phone*Cell Phone*Emergency Contact Name, # & Relation*Referring DoctorFamily DoctorArea of Injury/Diagnosis*May we contact you via email?*YesNoEmail Address* Billing InformationPrimary Insurance ProviderPrimary Insurance Policy #Primary Insurance ID #Secondary Insurance ProviderSecondary Insurance Policy #Secondary Insurance ID #WCB/MPI InformationWCB or MPI?WCBMPIClaim NumberDate Of Incident MM DD YYYY Adjustor NameReferralHow did you find out about us?*(Check all that apply) Friend/Relative Internet Print Ad Been Here Before Medical Professional Other Medical HistoryDo you presently or have you ever suffered from any of the following?(Check all that apply) Heart Problem HIV/AIDS High Blood Pressure Arthritis High Cholesterol Fainting Stroke Depression Lung Problems Anxiety Cancer Seizures/Epilepsy Diabetes Kidney Problems Osteoporosis Fracture Skin Disease/Sensitivity Circulatory Disorder Asthmas Hepatitis Could you be pregnant?*YesNoDo you have a pacemaker?*YesNoPlease list any medications you are currently taking:Do you suffer from any allergies?(if so, please list)Patient Consent*I hereby give consent to Caitlin Trakalo to provide a physiotherapy assessment and treatment based upon our discussed, mutually agreed goals. I understand I am responsible for all costs incurred and that payment is due after each treatment. I consent to having my medical information release to third parties, e.g. Physician, third party insurance companies if necessary. My signature acknowledges that I accept and understand the above information. I agree to the above terms Your Signature*Use your mouse to sign, or your finger if you are on a phone or touch device.PhoneThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.