MVA Intake Form by ME18e9X


									Please Print Clearly

Name: _____________________________________________Gender: __________________

Address: ________________________________________ Date of Birth:________________
City: _______________________________________________Postal Code:_______________
E-mail Address (access personalized exercise programme/appt reminders)_______________________
Do you want to receive our e-newsletter? Yes____  No_____
Family Doctor: _________________________________AB Health No. _________________
Emergency Contact: ______________________________Phone Number: ________________
Relationship to contact: _________________________________
              Please inform your therapist if you are pregnant.

Were you referred to us from your doctor/dentist. Yes___________ No __________
Referring Doctor ______________________ Referring Date___________________________

Please tell us how you heard about us: (Please check all that apply)

   Doctor                  Returning Patient
   Family/Friend-(If yes, whom is it?)_______________________________________
   (May we thank this person for the referral?) yes____ no_____
   Website _________________________________________________________
   Google / Canada 411________________________________________________

Are you a member of Alberta School Employee Benefit Plan, or do you have Blue Cross
Yes ______No ________ ID #____________ Group #___________
Do you have any other private health care coverage? Yes_____ No________

      Please fill in the appropriate spaces for Motor Vehicle Accident Patients

Is this a Motor Vehicle Accident: ____________ Date of accident: ________________

Billing Insurance:
        Name of insurance __________________________________________________
        Insurance address ___________________________________________________
        Policy/Claim No. ___________________________________________________
        Insurance Phone No. ________________________ Fax ____________________
        Insurance Contact Person _____________________________________________
             It is critical to have all insurance information filled in properly. Any
               information that is not filled in may result in invoices forwarded to
               the patient.
                                            Informed Consent
I _____________________understand that I will be assessed by a Physical Therapist and a
treatment plan will be formulated with the diagnosis in mind. I consent to undergo
treatment at this facility, Peak Physical Therapy Ltd. I agree to optimize the treatment to
the best of my ability.
Signed ____________________________________________ Date _________

At Peak Physiotherapy we collect only information required for the provision of treatment
& for facilitation of payment. Personal information is not shared without consent except as
required by law. For further information ask for a copy of our full privacy policy.

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