Patient Registration Health Form

Chiro Patient Registration / Health Form Date Name * First Last * Last Address Apartment/Unit # City Postal Code Home Phone Business Phone Cell Phone Email * Date of Birth Emergency Contact Name Emergency Contact Phone Family Doctor Family Doctor Phone Family Doctor Address What brings you to the clinic today? When did your condition begin? Is your injury work related? Is this a Motor Vehicle Accident (MVA) If yes, what date did the accident occur? Section The Pain Drawing Visual Pain Scale – Please indicate your pain level with regard to your description Do you have any metal implants in your body? Please describe Do you take any medications on a regular basis? (i.e. Vitamins, birth control, Advil) If yes, please describe Medical Profile: Pre-existing medical conditions, please check all that apply Diabetes (Type 1 or 2) Pacemaker Migraines Headaches Cancer (Any type) Kidney Disease Heart Disease Thyroid Problem Asthma/Lung Issues Osteoarthritis Rheumatoid Arthritis Pregnant Osteoporosis/Osteopenia Ulcers Visual Problems Nausea Dizzy Spells/Vertigo hearing Problems High/Low Blood Pressure HIV Epilepsy Bleeding Tendencies Hepatitis Psychiatric Illness Abdominal/Intestinal Problems Stroke/Heart Attack If you answered “Yes” to any of the above, please provide details Do you have a medical condition for which you see a doctor or take medication regularly? If yes, please specify Do you have any allergies / sensitivities to drugs / tape /cream / heat / cold? Please describe Have you had any surgery, tumors, cancer or serious illness in the past? If yes, please specify Social History: Dependants: (#, age) Marital Status Occupation # of hours per week Physical Activities Sleep: hours/night Sleep Quality Sleep Position Do you smoke? What do you smoke? Amount per day/year Additional health information you would like to include If you are human, leave this field blank. Submit

Athletic Therapy in Downtown Toronto

Extended Health Insurance Direct Billing Policies

Last Name

First Name

Date of Birth

Gender

We are able to bill some (not all) insurance companies directly for your Physiotherapy, Massage Therapy, Chiropractic and Acupuncture treatments.
As the policy holder, it is your responsibility to contact your insurance company and confirm the exact details of your coverage including requirement for physician requisitions. Our front desk staff would be happy to assist you with any questions regarding your insurance coverage for our services.
You may be required to pay a deductible or make a co-payment if your insurance plan defines so. Deductibles & co-payments are due at the end of your visit. Any unpaid balances will be charged to your credit card on file.
We are only able to direct bill to your primary insurance plan. We are not able to do any co-ordination of benefits to secondary plans (spouse or other parent’s plans).
If you have been involved in a motor vehicle accident & have extended health insurance, your auto insurer requires your treatments to be billed to the extended health plan first. Please provide primary & secondary (if applicable) insurance information below:

Name of Insurance

Group/Policy/Plan #

Certificate/Member ID#

Name of Secondary Insurance

Group/Policy/Plan #

Certificate/Member ID#

By signing this Digital Signature a capture of your IP address and location will be submitted to Cardio-Go confirming your consent.

Digital Signature/Printed Name of Patient

If you are human, leave this field blank.

Athletic Trainers

What do Athletic Trainers treat?

SPORTS MEDICINE FORMS

Section

Medical Profile:

Social History:

Our Athletic Trainers

Kaitlin Kawam

Treat yourself

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