Patient Intake Form
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141 Caithness St. W., Caledonia, ON, N3W 2J2
Phone: (905)765-5449
email: ifeelgood@haldimandphysio.ca
Website:
Patient Intake Form
A
Intake Date:
Mr/Mrs/Miss/Ms
(last):
(first): ____________________________
Address: ________________________________________________________________________
City:
Postal Code: _____________________
Home Phone:
Work Phone:
Cell Phone: _____________
Your Email Address: ___________________________________________________________________
*by providing your email you are consenting to receive appointment reminders/ newsletter. Your email address will never be
shared and you can unsubscribe at any time.
Birth Date (D/M/Y):
/
/
Family Doctor: __________________________________
How did you find us?
o
I am a past patient
○ Family doctor specifically referred me to this clinic
o
Friend/family member recommended this clinic. Who? ____________________________________
o
Clinic Sign
○ Internet Search
○ Website ( )
o
Bell yellow pages OR Goldbook
○ Mail out
○ Newspaper
○ Facebook
o
Other ____________________________________________________________________________
B
Motor Vehicle Accident (MVA) Claims:
Name of Insurance Co: __________________________________________________________________
Address of Insurer: ____________________________________________________________________
MVA Claim No:
Policy No: ______________________________
Adjustor Name:
Phone No: _______________________________
Name of Insured:
Date of Accident: ________________________
□
□
Extended Health Benefits? Yes
No
□
□
I am covered by more than one extended health plan?
Yes
No
If you or your spouse have extended benefits through a health plan (at work), the Auto Insurance legislates that you
MUST use these benefits first. Any additional uncovered costs will usually be covered by the Auto Insurer.
Extended Health Company: ______________________________________________________________
Name of Policy Holder:___________________________ Policy Holders Date of Birth: _______________
Policy No:
ID # _______________________________________
Max/ Year PT coverage:
___ Max/ visit PT coverage: _________________________
C
WSIB Claims:
WSIB Claim#:
SIN (if no claim #) : _______________
Date of Injury/ Re Injury:
Occupation:
____
Employer: ____________________________________________________________________________
Supervisor Contact Name and #: _________________________________________________________
Documents/forms/intake forms/Patient Intake Form.2014
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