NovaCare Health and Wellness Centre - Physiotherapy in Thunder Bay

Online Intake Form

WSIB Intake Form

Please complete all sections of this form to help us provide you with the best care following your workplace accident.

Patient's Personal Information

First Name

Last Name

Date of Birth

Phone Number

Email Address

Home Address

Details of Injury

Date of Accident

Time of Accident

Location of Accident

Description of Injuries

Have you been assessed by anyone else for this injury?

Yes No

If yes, please provide details (healthcare provider name, facility, date):

Do you have legal representation for this workplace injury?

Yes No

Lawyer/Legal Representative Name:

Law Firm:

Lawyer's Phone Number:

Lawyer's Email:

WSIB Information

Has a claim been opened with WSIB

Yes No

If yes, date opened:

WSIB Claim Number:

Signature:

SIGNATURE INDICATES YOU HAVE OPENED A FILE WITH WSIB

Extended Health Benefits

Primary Insurance Provider

Insurance Company

Policy/Plan Number

Member ID/Certificate Number

Policyholder Name (if not you)

Coverage Limit ($)

Coverage Percentage (%)

Secondary Insurance Provider (if applicable)

Insurance Company

Policy/Plan Number

Member ID/Certificate Number

Policyholder Name (if not you)

Coverage Limit ($)

Coverage Percentage (%)

WSIB - Cancellation and Payment 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.

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.

By signing below, you understand and agree to the cancellation and payment policy.

Patient Signature:

Witness Signature:

I consent to the collection and use of my personal information for the purpose of providing healthcare services. I understand that my information will be kept confidential and secure.

Transform Your Health at NovaCare

Online Intake Form

WSIB Intake Form

Patient's Personal Information

Details of Injury

WSIB Information

Extended Health Benefits

Primary Insurance Provider

Secondary Insurance Provider (if applicable)

WSIB - Cancellation and Payment Policy