Physiotherapy Intake Form

Please complete this form before your first physiotherapy appointment. All information is confidential and helps us provide the best possible care.

15-20 minutes

Secure & Confidential

Auto-saves Progress

1Personal Info 2Medical History 3Pain & Goals 4Consent

Personal Information

Please provide your contact details

Clinic Location *

Last Name *

First Name *

Date of Birth *

Street Address *

City *

Postal Code *

Primary Phone Number *

Alternate Phone Number

Email Address *

Your email address will only be used by our clinic to communicate with you. It will not be sold or distributed.

Emergency Contact

Emergency Contact Name *

Emergency Contact Phone *

Family Physician Information

Family Doctor Name

Doctor's Address/Clinic

How did you hear about Back on Track? *

Guardian Information (If Patient is Under 16)

Guardian Name

Relationship to Patient

Guardian Phone (if different)

Informed Consent

Please read and acknowledge

Physiotherapist Informed Consent

As a matter of ethics and law there is an obligation, prior to examination and treatment, to disclose any material risk to the patient to obtain a valid informed consent.

As part of the physiotherapy treatments, certain procedures and devices may be utilized such as the use of heat, ice, electrotherapy, ultrasound, massage and manual therapy.

As part of the rehabilitation program (kinesiologist, occupational therapist or physical therapist assistant) certain testing procedures, devices and equipment may be utilized such as weight machines, exercise, cardiovascular work and functional tasks.

I have had the opportunity to discuss with the physiotherapist and/or other clinical staff, the nature and purpose of treatments. I understand the results are not guaranteed.

I further understand, and I am informed that there are some very slight risks to treatments, including, but not limited to, muscle strains, sprains, disc injuries, and burns have been made aware that there are remote chances of injury and that appropriate tests will be performed to help identify if I may be susceptible to risk or injury.

Authorization to Disclose Information

Consent to share information with relevant parties

Your Full Name *

Your Full Address *

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:

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.

Cancellation Policy

Please review and acknowledge our policy

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, and it must be paid by you for you to continue to be treated under your claim. Under certain circumstances management may waive this fee.

Date

Date of Birth

Date of Loss (if applicable)

Claim # (if applicable)

Agreement & Signature

Please review and sign below

Accuracy of Information: The above information is true to the best of my knowledge. * Informed Consent: I have read and understand the informed consent for physiotherapy treatment and agree to proceed with evaluation and treatment. * Cancellation Policy: I have read, understand, and agree to the cancellation and payment policy stated above. * Payment Policy: I understand that payment for services is due at the time of my appointment. *

Patient / Guardian Signature

Print Full Name *

Electronic Signature *

Date *

Witness (Optional)

Witness Name

Witness Signature

Date

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

Physiotherapy Intake Form

Personal Information

Emergency Contact

Family Physician Information

Guardian Information (If Patient is Under 16)

Medical History

Musculoskeletal Conditions

Cardiovascular Conditions

Neurological Conditions

Systemic / Other Conditions

Medications & Other Conditions

Pain Assessment & Treatment Goals

Where is your pain located? *

Pain Intensity *

Activities Affected

Treatment Goals *