Chiropractic Intake Form - MOVE Physiotherapy

Personal Information

Name*

First Middle Last

How did you hear about us?*

Mailing Address*

Street Address Address Line 2 City Province Postal Code

Phone – Home

Phone – Cell*

Phone – Work

Email*

Birthdate*

Health Card #*

Occupation

Gender

Emergency Contact*

Phone*

Relationship*

Reason for appointment today*

What makes your complaint better?*

What makes your complaint worse?*

When did your complaint begin?*

What is your current level of pain?

Is this related to a car accident?*

No
Yes

Is this related to a work injury?*

No
Yes

Consent for Release of Information

Consent

I authorize MOVE Physiotherapy to use my mailing address, phone number and email address for appointment reminders and treatment follow up.

I authorize MOVE Physiotherapy to use and disclose my medical information for purposes of treatment, payment and health care to the following:

Family Physician

Family Physician

Physician Name*

Personal Healthcare Insurer

Personal Healthcare Insurer

Insurer*

Policy #*

Member/ID #*

Policy Holder Name*

Date of Birth*

Motor Vehicle Insurance Provider

Motor Vehicle Insurance Provider

Worker’s Compensation Board

Worker’s Compensation Board

I understand that I have the right to revoke this consent provided that I do so in writing, except to the extent that MOVE Physiotherapy has already disclosed the information based on this consent.

Health History

Are you presently being treated for any health conditions?

No
Yes

Please list health conditions*

Please list any family medical history/conditions

Are you presently taking any medications/vitamins/supplements?

No
Yes

Please list medications/vitamins/supplements*

Are you currently pregnant?

No
Yes

Due Date*

Are you or were you ever a smoker?

No
Yes

Please list previous injuries and/or surgeries

Have you been to chiropractic in the past?

No
Yes

Can you perform daily home/work activities?

All
Some
With help
Not at all

Please check any that apply, past or present:

Heart Condition, please list*

Stroke/CVA date*

Pacemaker year of insertion*

Swelling/Edema cause if known*

Cancer, please list type and dates*

Diabetes, please list type*

Osteoporosis, year of diagnosis*

Fibromyalgia, year of diagnosis*

Hepatitis, list type*

Epilepsy, is it controlled*

No
Yes

Date of last seizure*

Skin condition, please list*

Bowel/Bladder/GI Issues, please specify*

Respiratory Issues, please specify*

Allergies, please list*

Presence of internal pins, plates, screws or artificial joints, please list*

Are you currently immunocompromised?*

No
Yes

Please list anything else that your therapist should be aware of

Cancellation/Late Policy

If you are unable to attend your scheduled appointment, we require 24 hours notice, for cancellations or rescheduling. If you fail to do so, a charge equal to 50% of the appointment in question, will be charged. If you do not show for an appointment, then you will owe for the full charge of that appointments . Cancelation charges can not be covered through Extended Health Care benefits, MVA/WCB Insurers or MSI. If calling outside of business hours, please leave a detailed message. If you arrive 15 minutes or more past your scheduled appointment time you may be asked to reschedule and have a cancellation charge applied to your account.

Payment Agreement

MSI does not cover any of MOVE’s services; therefore you, the patient, are responsible for payment of services rendered. Payment is due at the time of your appointment. Many patients have Extended Health Care (EHC) Benefits to offset the cost of our services. We direct bill most, if not all EHCs, the Worker’s Compensation Nova Scotia and Motor Vehicle Insurers. It is your responsibility to know the details of your own plan. If you are covered under more than one policy, please note that we will only bill the primary policy. Any fees above this amount are your responsibility. (MOVE Physiotherapy reserves the right to refuse direct billing to any insurance company).

Please Note: If your claim is refused or denied by Worker’s Compensation Board, your Motor Vehicle Insurer or your personal Healthcare Insurer, you are responsible for all payments for services rendered. These fees may include, but are not limited to the following: treatment fees, product fees and fees for any forms completed during treatment.

Consent*

I accept

By submitting this form, you are acknowledging MOVE Physiotherapy’s Cancelation/Late Policy and Payment Agreement