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

Chiropractor in Downtown Toronto

What Is Chiropractic Care?

Chiropractic care is one of the largest primary health care professions in Ontario. It is an evidence-informed, non-invasive, hands-on discipline that focuses on diagnosing and treating conditions related to the **musculoskeletal system**, including the **spine, muscles, joints, pelvis, and nervous system**.

At Higher Ground in Toronto, our chiropractors use manual techniques to deliver personalized, effective treatments. Each patient receives a tailored care plan based on a comprehensive health history, physical examination, and clinical diagnosis. Our approach includes therapeutic exercise, **non-invasive manual therapy**, and lifestyle guidance such as nutritional and postural counseling.

What Is Spinal Manipulative Therapy (SMT)?

**Spinal Manipulative Therapy (SMT)**—commonly referred to as a chiropractic adjustment—is a precise, skilled technique used to restore mobility and function to spinal joints. This high-velocity, low-amplitude thrust is applied to a specific vertebra to help alleviate pain, reduce stiffness, and improve range of motion. You may hear a popping sound during the adjustment, which is simply a gas bubble being released from the joint capsule—similar to cracking your knuckles.

At Higher Ground, SMT is performed by experienced chiropractors in a safe, comfortable setting, helping you move and feel better naturally.

HigherGround offers Chiropractic Care near Yonge and College in downtown Toronto at 382 Yonge Street, steps from College Station.

What Do Chiropractors Treat?

Back pain
Neck pain
Headache
Whiplash
Strains and sprains
Repetitive strain injury (RSI)
Work and sports injuries
Arthritis
Nerve-related conditions (ex. Sciatica, Carpal Tunnel Syndrome, etc.)
Limited range of motion in the back, shoulder, neck or limbs

Initial Assessment $125

Initial Assessment with Treatment $160

Treatment $95

Extended Treatment $135

Orthotic Insert $500
(Includes consult, fitting & Orthotic insert)

CHIROPRACTIC FORMS

To better serve you, please fill out the forms below after you have booked your appointment, thank you.

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Extended Health Insurance Direct Billing Policies

Last Name

First Name

Date of Birth

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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

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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.

Our Chiropractors

Paul Joseph Glancey

Paul is originally from Cape Breton, Nova Scotia, and received a Bachelor of Science and a Bachelor of Education from Cape Breton University. He then moved to Toronto to complete his Chiropractic studies at the Canadian Memorial Chiropractic College. After graduating from the Doctor of Chiropractic program, Paul received a Strength & Conditioning Specialist Certification from the National Strength & Conditioning Association.

Caitlin Mangiapane

Dr. Caitlin Mangiapane is from Bolton, Ontario and earned her Bachelor of Science in Kinesiology from York University. She then pursued her Doctor of Chiropractic degree at Northeast College of Health Sciences in New York.

What Is Chiropractic Care?

What Is Spinal Manipulative Therapy (SMT)?

CHIROPRACTIC FORMS

Section

Medical Profile:

Social History:

Our Chiropractors

Paul Joseph Glancey

Caitlin Mangiapane

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