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)This spot is specifically held for you. Late cancellations prevent others from attending, delays your recovery and opens time in the therapists working schedule. If you cancel an appointment within the 24-hours, or do not come to an appointment without notice, the following actions will be taken: First Late Cancellation/No-Show Second Late Cancellation/No-Show Third Late Cancellation/No-Show Warning with reminder about cancellation policy $40 cancellation fee will be charged to you and payment is due before treatment can continue We will no longer continue with treatment, and you will be discharged. A 24 hour notification is required to cancel or reschedule an appointment. I understand I will be responsible for a $40.00 fee if insufficient notice is provided. Treatment will not continue until payment is remitted. My signature acknowledges that I accept and understand the above information.Accept Cancellation Policy* By Checking this box, I acknowledges that I accept and understand the above information. Patient Consent* In order for physiotherapy treatment to be effective, I must come to scheduled appointments unless there are unusual circumstances. By following a personalized plan of treatment (number and frequency of appointments, and exercises) recovery will occur in a timely manner. Cancelling or missing appointments will make my recovery take longer. I hereby give consent to Caitlin Trakalo to provide a physiotherapy assessment and treatment via digital physiotherapy and/or in person based upon 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 eg. Physician, third party insurance companies if necessary. My signature acknowledges that I accept and understand the above information. Your Signature*Use your mouse to sign, or your finger if you are on a phone or touch device.NameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.