NEW PATIENT INTAKE FORM

In order to provide you with the best possible care, please complete this form to the best of your ability.

All information is STRICTLY CONFIDENTIAL.

First Name *

Last Name *

Date of birth *

Email *

Mobile Phone *

Home Address *

Family Doctor

How Did Hear About Us?

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Facebook/Instagram
Google
Friend/Family
Medical Doctor
Other
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MEDICAL HISTORY

Please ✔ if you have a family history of the following:

Family Medical Hx

Cancer

Lung Disease

Heart Disease

High Cholesterol/ Blood Pressure

Multiple Sclerosis

Diabetes

Thyroid Disease

Pregnant

At the best of my knowledge I am pregnant

At the best of my knowledge I am NOT pregnant

Please indicate if you have had or currently suffer from any medical conditions:

Medical Hx

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AGREEMENT

ELECTRONIC TRANSMISSION AUTHORIZATION AND CONSENT FORM.

I authorize my healthcare providers to submit claims on my behalf to my plan administrator. I authorize my healthcare provider to collect, use and disclose personal information concerning any claims submitted on my behalf with the insurer and/or plan administrator and their service provider(s) for the above purposes.

AUTHORIZATION FOR RELEASE OF PERSONAL HEALTH INFORMATION.

I authorize my healthcare provider to collect, use and disclose personal health information for the purposes of diagnosing or providing treatment to me, submitting claims, obtaining hospital, medical, vocational and other related records and to discuss pertinent information with any or all parties involved in my treatments.

ASSIGNMENT OF INSURANCE BENEFITS/ PAYMENTS GUARANTEE.

I authorize payment to be made directly to Spinal Solution Inc. for any services rendered and / or supplies provided. I hereby agree to bring in any cheque that the insurance company sends me to pay for any/all part of my therapy and I am personally liable for the amount if the cheque is cashed and funds not paid to Spinal Solution Inc.

By signing below I have read and understand this agreement and I accept and agree to all of it's terms and conditions.

Signature *

Clear

Date *

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CANCELLATION/ NO-SHOW POLICY

Any cancellations with less than 24 hours notice and any missed appointments will be charged a fee of $50.00. This fee is charged to your credit card on file and will be donated to Sick Kids Foundation and NOT a means to generate revenue for the clinic.

Please Note: We do not bill your credit card for treatments.

To assist you, we will send out an SMS and Email reminder the day prior to your appointment. Ultimately, your care the most important to us, and being able to attend your full treatment session as scheduled is necessary to get the best results in a timely manner.

Credit Card Authorization Form

Credit Card

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MasterCard
Visa
Amex
Other
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Cardholder Name

Expiration

Card Number

CVC

Postal code

By signing below, I agree to the above conditions and am aware of the associated charges should I not provide 24 hours’ notice or fail to attend my appointments.

Signature

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Full Name