ADDRESS 275 LANCASTER ST W • KITCHENER, ON • N2H 4V2 PHONE (519) 8855290 • FAX (519) 9547719 • EMAIL [email protected]WWW.HEALTHMOMENTUM.CA Intake Form and Consent Name: ________________________________________________________________________ Date of Birth: _____________________________________Age: _________________________ Address: ______________________________________________________________________ City: _________________________________________ Postal Code: _____________________ Phone Number Home: ______________________ Cell: ________________________________ E-mail Address: _________________________________________________________________ Occupation: ____________________________________________________________________ Family Doctor: _____________________________ Phone Number: ______________________ Referred By: ____________________________________________________________________ Primary Concern / Complaint: __________________________________________________________________________________ __________________________________________________________________________________ Indicate Location of Pain, Discomfort, Numbness, Tingling and/or Tightness below:
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ADDRESS 275 LANCASTER ST W • KITCHENER, ON • N2H 4V2 PHONE (519) 885-‐5290 • FAX (519) 954-‐7719 • EMAIL [email protected]
WWW.HEALTHMOMENTUM.CA
Intake Form and Consent
Name: ________________________________________________________________________ Date of Birth: _____________________________________Age: _________________________ Address: ______________________________________________________________________ City: _________________________________________ Postal Code: _____________________ Phone Number Home: ______________________ Cell: ________________________________ E-mail Address: _________________________________________________________________ Occupation: ____________________________________________________________________ Family Doctor: _____________________________ Phone Number: ______________________ Referred By: ____________________________________________________________________ Primary Concern / Complaint: __________________________________________________________________________________ __________________________________________________________________________________ Indicate Location of Pain, Discomfort, Numbness, Tingling and/or Tightness below:
ADDRESS 275 LANCASTER ST W • KITCHENER, ON • N2H 4V2 PHONE (519) 885-‐5290 • FAX (519) 954-‐7719 • EMAIL [email protected]
WWW.HEALTHMOMENTUM.CA
Please List Any Previous Injuries and/or Accidents: 1. _________________________________________________ Date: _________________ 2. _________________________________________________ Date: _________________ 3. _________________________________________________ Date: _________________ Please List Any Previous Surgeries: 1. _________________________________________________ Date: _________________ 2. _________________________________________________ Date: _________________ Please List Any Medications Taken In the Past 6 Months: 1. _________________________________________________ Purpose: ______________ 2. _________________________________________________ Purpose: _____________ 3. _________________________________________________ Purpose: ______________
ADDRESS 275 LANCASTER ST W • KITCHENER, ON • N2H 4V2 PHONE (519) 885-‐5290 • FAX (519) 954-‐7719 • EMAIL [email protected]
WWW.HEALTHMOMENTUM.CA
INFORMED CONSENT TO OSTEOPATHIC MANUAL TREATMENT
I understand that the Osteopathic Manual Therapist is providing osteopathic manual therapy services within their scope of practice. I hereby consent to my Osteopathic Manual Therapist to treat me with Osteopathic manual therapy for the above noted purposes including such assessments, examinations and techniques, which may be recommended by my Osteopathic Manual Therapist. I acknowledge that the Osteopathic Manual Therapist is not a physician and does not diagnose illness or disease or any other physical or mental disorder. I clearly understand that osteopathic manual therapy is not a substitute for a medical examination. It is recommended that I attend my personal physician for any ailments that I may be experiencing. I acknowledge that no assurance or guarantee has been provided to me as to the results of the treatment. I acknowledge that with any treatment there can be risks and those risks have been explained to me and I assume those risks. I acknowledge and understand that the Osteopathic Manual Therapist must be fully aware of my existing medical conditions. I have completed my medical history form as provided by my Osteopathic Manual Therapist and have disclosed to the Osteopathic Manual Therapist all of those medical conditions affecting me. It is my responsibility to keep the Massage Therapist updated on my medical history. The information I have provided is true and complete to the best of my knowledge. I authorize my Osteopathic Manual Therapist to release or obtain information pertaining to my conditions(s) and/or treatment to/from my other caregivers or third party payers. I have read the above noted consent and I have had the opportunity to question the contents and my therapy. By signing this form, I confirm my consent and I have had the opportunity to question the contents and my therapy. By signing this form, I confirm my consent to treatment and intend this consent to cover the treatment discussed with me and such additional treatments as proposed by my Massage Therapist from time to time, to deal with my physical conditions and for which I have sought treatment. I understand that at any time I may withdraw my consent and treatment will be stopped. CANCELLATION POLICY Patients are required to provide 2 business days notice for any cancellation. That time has been reserved for you and we appreciate having adequate time to fill the spot. The clinic reserves the right to charge the full fee for a missed appointment or an appointment cancelled with less than 2 business days.
ADDRESS 275 LANCASTER ST W • KITCHENER, ON • N2H 4V2 PHONE (519) 885-‐5290 • FAX (519) 954-‐7719 • EMAIL [email protected]
WWW.HEALTHMOMENTUM.CA
PRIVACY POLICY FOR COLLECTION, USE, AND DISCLOSURE OF PERSONAL INFORMATION Privacy of your personal information is an important part of our clinic, while providing you with quality Osteopathic care. We understand the importance of protecting your personal information. We are committed to collecting, using and disclosing your personal information responsibly. We will try to be as open and transparent as possible about the way we handle your personal information. All staff members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us. They are trained in the appropriate use and protection of your information. Our privacy policy outlines what our clinic is doing to ensure that: • Only necessary information is collected about you; • We only share your information with your consent; • Storage, retention and destruction of your personal information complies with existing legislation, and privacy protection protocols; HOW OUR CLINIC COLLECTS, USES, AND DISCLOSES PATIENTS’ PERSONAL INFORMATION This clinic will collect, use and disclose information about you for the following purposes: To assess your health concerns, to provide excellent and comprehensive health care, to advise you of treatment options, to remind you of upcoming appointments and to communicate with other treating health-care providers. By signing the consent section of this Patient Consent Form, you have agreed that you have given your informed consent to the collection, use and/or disclosure of you personal information as outlined above. I have reviewed the above information that explains how your clinic will use my personal information, and the steps your clinic is taking to protect my information. I agree that Health Momentum can collect, use and disclose personal information about me as set out above in the information about the clinic’s privacy policies. Patient Signature: ___________________ Therapist Signature: _________________ Date: ________________
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