MIG / MVA INTAKE
Name
:
M / F
DOB:
Date of Accident:
Physiotherapist:
Initial Appointment Date:
Time:
Guardian:
Relationship
Minor / Senior
Address:
Phone (H):
Phone (C):
City:
Phone (W):
Postal Code:
Other:
Obtained verbal consent for client to send electronic messages
Email address:
Extended Health Benefits / Private Coverage?
Yes
No
* If there are extended health benefits, they must exhausted first before we can begin to bill the auto insurance
company. This is regulated by insurance law.
Physio – Extended Health Limits:
And % of Coverage
Massage – Extended Health Limits:
And % of Coverage
Family Doctor:
Phone:
Address:
Fax:
City:
Postal Code:
I agree to pay for services rendered and submit a claim to my personal plan until my extended health benefits have
been exhausted. Policy for Appointment Cancellation: We require 24 hours notice of any change in your reserved
appointment, in order to avoid being billed. When you fail to show for a schedules appointment you have taken the
physiotherapist’s time, but just as important, prevented another patient from being seen.
Signature: ________________________________________________ Date: __________________________________
Motor Vehicle Insurance Company Name & Address:
Claim #
Policy #
Adjuster Name:
Phone:
Fax:
Additional information:
Form 103, Nov 2015