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 *FirstLastBirth Date *MM/DD/YYYYPhone Number *EmailAddress *Postal Code *City *Referring 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 SurgeryDate of Cast RemovalSplint, Brace or Half Slabif you are in a movement limiting device already, please describe itSplint needed?NoYesUnsureImagingX-RAYMRIUltrasoundEMGCTNo ImagingPlease select the types of imaging you have had for this case. Imaging LocationWhere did you have your imaging done? (IE TBRHSC, Thunder Bay Diagnostic, etc)Do 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. NOTE: 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.WSIB Claim NumberWSIB Cases onlyDate of AccidentWSIB Cases onlyEmployerWSIB Cases onlyJob TitleWSIB Cases onlySingle Line TextSubmit