New Client Information

Submit this form to be contacted by our front desk staff to get in and see one of our therapists.

Please note: We are a private clinic, not covered by OHIP, we do not do any direct billing unless it is MVA or WSIB, and we do not bill to NIHB.

Name *

First

Last

Birthdate *

MM/DD/YYYY

Email *

Phone *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Referring Doctor

Family Doctor

Other

Self Referred

Diagnosis

Describe your symptoms *

If you have seen a doctor or practitioner try to use their verbiage as well as including your own description. Let us know how long you've been experiencing symptoms, sensations, and triggers. If it is related to a specific accident please describe.

Date of Injury

or length of time experiencing symptoms

Date of Surgery

if applicable

Date of Cast Removal

if applicable

Splint, Brace or Half Slab

if you are in a movement limiting device already, please describe it.

Splint/Brace needed?

Do we have your permission to request a copy of your imaging reports?

Extended Health Coverage *

Note; we are a private clinic and DO NOT DO DIRECT BILLING except for WSIB and MVA cases.

All appointments are PAID FOR BY THE PATIENT and receipts can submitted for reimbursement to your extended healthcare provider.

If we book you for a type of therapy you say you have coverage for here but do not, you will be paying out of pocket. Please double check your coverage to ensure reimbursement

*Most plans do not include Occupational Therapy.*

WSIB/MVA Information

WSIB Claim Number

WSIB Cases only

Date of Accident

WSIB Cases only

Employer

WSIB Cases only

Job Title

WSIB Cases only

Comments

Anything else we should know?