Physiotherapy Patient Registration Form

Personal Information

Patient Name*

First Last

Date of Birth*

Street Address*

City*

Postal Code*

Preferred Contact*

Home Phone*

Work Phone

Cell Phone*

Email*

Emergency Contact

Emergency Contact Name

Emergency Contact Phone Number

Referral Information

Referring Source*

Family Physician*

Is this a WSIB Claim?*

Yes
No

WSIB Claim Information

WSIB Claim Number*

Date of Injury*

Extended Health Insurance

Insurance Carrier

Employment Information

Employer

Occupation

Is the patient a minor (below 16 years of age)?*

Yes
No

Parent/Guardian (if patient is a minor)

Name*

First Last

Street Address*

City*

Postal Code*

Pre-Authorized Payment for Minors*

Yes
No

Health Information

Complaint*

(Reason for visit)

Previous Physiotherapy for above complaint?*

Yes
No

Previous Surgery/Illness (with dates)

Current Medications

Other Medical Conditions

Females – Is there any possibility you are pregnant?

Yes
No

Are you receiving any other treatment at this time?*

Yes
No

Do you have metal in your body?*

Yes
No

(Pacemaker, screws, joint replacements, etc.)

Patient Consent

Please read the follow statements and sign below:

I consent to an examination and treatment performed by a licensed physiotherapist. The results of this exam will be used to develop a treatment plan to meet my specific goals. I understand that my treatment may involve physical and electric modalities, acupuncture, stretching or mobilizations and exercise programs.
I understand that MSK Rehabilitation and Bracing is jointly owned by Robert Chalmers, Dr. Nick Bayley, Dr. Chris Geddes, Dr. Paul Grosso, Dr. Tom Hupel, Dr. Rick Lau, Dr. Matthew Snider and Dr. David Stevens. As such I realize that I may attend the clinic of my choice.
I understand that I may stop the assessment or treatment procedure at any time
I understand that if at any time I am not comfortable with, and/or do not understand the treatment being received I will ask the physiotherapist for further clarification
I must inform my physical therapist of any contagious or infectious condition I may have
I understand that parts of my program may be provided by an assistant under the direction of my physiotherapist

Health Information Custodian: Robert Chalmers – MSK Rehabilitation – 519-603-0641

My signature below indicates that I have read and understand all of the above information.

Initials of Client*

Parent/Guardian Name*

Initials of Parent/Guardian*

Today's Date*

Phone

This field is for validation purposes and should be left unchanged.