Patient Intake Form

Please feel free to complete our Patient Intake Form below before your first visit or if you are doing distance therapy.

  • General Information

  • Billing Information

  • WCB/MPI Information

  • Referral

  • (Check all that apply)
  • Medical History

  • (Check all that apply)
  • (if so, please list)
  • 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.
  • Use your mouse to sign, or your finger if you are on a phone or touch device.
  • This field is for validation purposes and should be left unchanged.