New Client Information Submit this form to be contacted by our front desk staff to get in and see one of our therapists Please enable JavaScript in your browser to complete this form.Name *FirstLastBirthdateMM/DD/YYYYEmail *PhoneAddressAddress Line 1Address Line 2CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryReferring DoctorFamily Doctor OtherSelf ReferredDiagnosisDescribe 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 Injuryor length of time experiencing symptomsDate of Surgeryif applicableDate of Cast Removalif applicableSplint, Brace or Half Slabif you are in a movement limiting device already, please describe it.Splint/Brace needed?NoYesUnsureImaging *XRayUltrasoundMRIEMGCTOtherNo ImagingHave you had any imaging done or scheduled?Other Imaging:Imaging LocationThunder Bay Regional Health Science CenterThunder Bay DIagnosticThunder Bay UltrasoundOtherWhere did/will you have imaging done?Other Imaging LocationBody Part for ImagingHandWristForearmElbowUpper ArmShoulderNeckChestOtherWhat part of your body is imaging for?Other Body Part ImageDo we have your permission to request a copy of your imaging reports?YesNoExtended Health CoverageI do not have any coverage; I understand I will be self-payingI have Physiotherapy CoverageI have Physiotherapy and Occupational Therapy CoverageI am a WSIB or MVA CaseNote; 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 InformationWSIB Claim NumberWSIB Cases onlyDate of AccidentWSIB Cases onlyEmployerWSIB Cases onlyJob TitleWSIB Cases onlyCommentsAnything else we should know?Submit