Chiropractic Intake Form

Please complete this form before your first chiropractic appointment. All information is kept strictly confidential.

Takes approximately 10-15 minutes

Secure & Confidential

Required fields

1 Personal Info 2 Medical History 3 Current Condition 4 Consent

Personal Information

Please provide your contact details

Clinic Location *

First Name *

Last Name *

Date of Birth *

Gender *

Address *

City *

Province *

Postal Code *

Phone Number *

Email Address *

Occupation

Emergency Contact

Contact Name *

Relationship *

Phone Number *

Family Physician Information

Physician Name

Physician Phone

Insurance Information

Please provide your insurance details if applicable

Insurance Provider

Policy Number

Group Number

Certificate/ID Number

Claim Type

Extended Health Motor Vehicle Accident (MVA) WSIB Self Pay

Cancellation Policy

Please review and acknowledge our cancellation policy

Date *

Patient Name *

Date of Birth *

Date of Loss (if applicable)

Claim # (if applicable)

We understand that unplanned issues may come up and you will need to cancel an appointment. If this happens, we respectfully ask that you notify us at least 24 hours prior to your appointment time.

Our therapists want to be available to meet your needs as well as the needs for all of our patients. When a patient does not show up for a scheduled appointment, another patient loses the opportunity to be seen.

Missed Treatment Charges

If we are not provided with the appropriate notice, you will be responsible for a Missed Treatment charge of $50.00.

For Missed Massage Treatments (in accordance with the RMTAO):

2nd missed massage – 50% of the massage fee
3rd missed massage – 100% of the massage fee

This charge will not be billed to any third-party payors. You will be billed directly, and payment must be made by you for you to continue to be treated under your claim.

Under certain circumstances, management may waive this fee.

I understand and agree: By checking this box, I confirm that I have read, understand, and agree to the cancellation and payment policy stated above. *

Patient Signature

Patient's Full Name *

Electronic Signature *

Witness (if applicable)

Witness Name

Witness Signature

Lifestyle Information

Help us understand your daily activities

How would you describe your activity level?

What type of work do you do?

Do you participate in any sports or recreational activities?

Do you smoke?

Yes No Former

Alcohol consumption?

Average hours of sleep?

Treatment Goals - What do you hope to achieve through chiropractic care?

Consent & Agreement

Please review and acknowledge the following

Informed Consent for Chiropractic Treatment

I understand that chiropractic treatment may include manual adjustments, soft tissue therapy, exercise recommendations, and other therapeutic procedures. I understand that while chiropractic care is generally safe, there are some risks, including but not limited to: temporary soreness, stiffness, or discomfort following treatment.

I understand that I have the right to ask questions about any aspect of my treatment and to decline any part of my care at any time. I acknowledge that no guarantees have been made to me regarding the outcome of treatment.

I authorize the chiropractor and clinic staff to perform assessments and treatments as deemed necessary for my condition. I agree to inform my chiropractor of any changes in my health status.

Confidential Consent, Authorization & Direction to Disclose Personal Information

I hereby consent to the sharing and/or exchange of written and/or verbal information between Back on Track Physiotherapy and the parties listed below.

Your Full Name *

Your Full Address *

Authorized Parties (Names and Institutions)

List the full names and institutions of affiliation for parties authorized to receive/share information:

Client Name (if different from above)

Client Date of Birth

Information to be released relates to the above-named injury or illness and pertains to the development of treatment and nutritional plans.

I understand that this consent is subject to revocation at any time, except for such action that has already been taken. A photocopy of this authorization shall have the same validity as the original.

Consent to Treatment: I have read and understand the above information and consent to chiropractic evaluation and treatment. * Privacy Policy: I acknowledge that my personal health information will be kept confidential and used only for the purpose of my healthcare as per PHIPA regulations. * Accuracy of Information: I certify that the information provided in this form is accurate and complete to the best of my knowledge. *

Electronic Signature (Type your full name) *

Date *

Your information is secure and will be reviewed by our clinical team