NovaCare Health and Wellness Centre - Physiotherapy and Massage Therapy in Thunder Bay

Personal Information

First Name *

Last Name *

Date of Birth *

Email *

Phone Number *

Address

Family Doctor Name

Family Doctor Clinic/Practice

Family Doctor Phone

How were you referred to our clinic?

Emergency Contact Name

Emergency Contact Phone

Medical History

What is your primary reason for seeking physiotherapy? *

Pain Level (0-10, with 10 being worst)

When did your symptoms start?

Have you had previous treatment for this condition?

Yes

No

Current Medications

Please list any medical conditions you have:

Previous Surgeries (with dates if known)

Authorization and Consent

I authorize NovaCare Health and Wellness Centre to collect, use, and disclose my personal information for the following purposes:

To assess my health concerns and provide healthcare services
To communicate with other healthcare providers involved in my care
To obtain payment for services provided, including billing insurance companies
To comply with legal and regulatory requirements
For quality improvement and risk management activities

I understand that I can withdraw my consent at any time by contacting the clinic.

I have read and agree to the authorization and consent to disclose personal information *

Cancellation Policy

We understand that situations arise that may require you to cancel. 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. If we are not provided with the appropriate notice, you will be responsible for a Missed Treatment charge of $50.00. For any Missed Massage Treatment, you will be charged in accordance with the RMTAO as follows: 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.

I have read and agree to the cancellation policy *

Physiotherapy 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.

Patient Signature *

Date *

Parent/Guardian Signature (if applicable)

Date

Witness Signature (Clinic Staff)

Date

I have read and understand the above consent and agree to physiotherapy assessment and treatment *

Welcome to NovaCare Health and Wellness Centre

Physiotherapy Patient Intake Form

Personal Information

Medical History

Authorization and Consent

Cancellation Policy

Physiotherapy Informed Consent