Unit 308 – 32625 South Fraser Way Abbotsford, BC V2T 1X8 PATIENT INFORMATION Patient’s Name: Today’s Date: Address: City: Postal Code: Care Card #: Primary Phone: Alt. Phone: Email: Age: Birth Date (yyyy/mm/dd): Occupation: Employer: Primary Physician: Physician’s City: Who Referred you to our office? CHIEF COMPLAINT Why are you seeing the therapist today? Current problem is a results of a: Are you currently involved in an active ICBC or WCB claim? Yes No if YES: ICBC/WCB Claim #: Date of Accident/Injury: Adjustor Name: Lawyer Name: Adjustor Phone Number: Lawyer Phone Number: HISTORY Date symptoms started or date injury occured: Area of body involved: Describe the problem: How often does this occur? How long does it last? What makes the problem better? What makes the problem worse? Indicate your level of pain: Car Accident Work Accident Sports Injury Other None Mild Moderate Severe Unbearable Abbotsford Sports & Orthopaedic Physiotherapy
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Unit 308 – 32625 South Fraser Way Abbotsford, BC V2T 1X8
PATIENT INFORMATION
Patient’s Name: Today’s Date:
Address: City:
Postal Code: Care Card #:
Primary Phone: Alt. Phone: Email:
Age: Birth Date (yyyy/mm/dd):
Occupation: Employer:
Primary Physician: Physician’s City:
Who Referred you to our office?
CHIEF COMPLAINT
Why are you seeing the therapist today?
Current problem is a results of a:
Are you currently involved in an active ICBC or WCB claim? Yes No
if YES:
ICBC/WCB Claim #: Date of Accident/Injury:
Adjustor Name: Lawyer Name:
Adjustor Phone Number: Lawyer Phone Number:
HISTORY
Date symptoms started or date injury occured:
Area of body involved:
Describe the problem:
How often does this occur?
How long does it last?
What makes the problem better?
What makes the problem worse?
Indicate your level of pain:
Car Accident Work Accident Sports Injury Other
None Mild Moderate Severe Unbearable
Abbotsford Sports &Orthopaedic Physiotherapy
Associated Symptoms (Check all that apply)
MEDICATIONS
List any medications taken for this problem or for other medical conditions:
Unit 308 – 32625 South Fraser Way Abbotsford, BC V2T 1X8Abbotsford Sports &
Orthopaedic Physiotherapy
pain
swelling
limited motion
locking or catching
giving out
nausea
weakness
tingling
numbness
fever / chills
redness
dizziness
pain worse at night
problem is constant
problem is intermittent
problem is activity related
headaches
fatigue
ASSIGNMENT OF MEDICAL SERVICES PLAN BENEFITS TO OPTED OUT PRACTITIONER
If any of the below billing scenarios apply to you please sign the following authorization below to allow us to bill a portion of your fee’s electronically through the medical service plan on your behalf.
Please check if you are eligible for Premium Assistance. It is your responsibility to let reception know for billing purposes if you qualify for this benefit.
Please check if you have an active ICBC claim.
Please check if you have an active WCB claim.
I, _________________________________ (Beneficiary) authorize the Medical Services Plan to pay Dan Bos, Tanya Bos, Brittany Galmut, Lianne Graham, Ryan Hik, Daryl Kindratsky or Raquel Foth (Practitioner) directly for all reimbursements for benefits payable to me under the Medical & Health Care Services Regulation for care provided to me by said Practitioner.
This form allows the above name practitioner to receive your MSP reimbursement directly for services that are MSP benefits. Your practitioner, by law, must advise you of his/her full fee and what portion will be reimbursed by MSP. By agreement, your practitioner may not charge you the portion reimbursed by MSP.
Signature of Patient: _____________________________________________
Date signed: ___________________
Fee Policy: The patient or guardian is always responsible for treatment fees.
Privacy Statement: By my signature below, I authorize the clinic and its associated RPTs to collect my personal and medical information as documented above in order to contact me, and give permission for the clinic to leave messages regarding appointments at any of the contact numbers I have provided above. In addition, I authorize the clinic and its associated RPTs to communicate with my referring MD as deemed necessary for my beneficial treatment. I also understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission.
By my signature below I confirm that I have read the foregoing and agree to the terms set out and give my consent to treatment.
Abbotsford Sports & Orthopaedic Physiotherapy #308-32625 South Fraser Way., Abbotsford, BC V2T 1X8 Phone: (604855-5157 Fax: (604)8555197 E-mail: [email protected]
INFORMED CONSENT TO PHYSIOTHERAPY TREATMENT
I hereby request and consent to the performance of physiotherapy manual/manipulative adjustments and other physiotherapy procedures/modalities on me (or on the patient named below, for whom I am legally responsible) by the licensed physiotherapist working at Abbotsford Sports & Orthopaedic Physiotherapy.
After the assessment and before any treatment, I will have the opportunity to discuss with the physiotherapist the nature and purpose of physiotherapy manual/manipulative adjustments and other physiotherapy procedures/modalities used to help my condition.
I understand and am informed that in the practice of physiotherapy there is some risk to treatment, including but not limited to: fractures, spinal disc injuries, dislocations, sprains, strains, soreness, modality burns, and strokes.
• There have been reported cases of stroke associated with many common neckmovements including adjustment of the upper cervical spine. Present medical andscientific evidence does not establish a definite cause and effect relationship betweenupper cervical adjustments and the occurrence of stroke. Furthermore, the apparentassociation is noted very infrequently. However, you are being warned of this possibleassociation because stroke sometimes causes serious neurological impairment, andmay on rare occasion result in injuries including paralysis. The possibility of suchinjuries resulting from cervical adjustments is extremely remote.
I understand and comprehend all such risks and complications. I, by my signature below, confirm and accept care and therefore consent to and agree to those treatments deemed by my physiotherapist to be in my best interest.
I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above named procedures. I intend for this consent form to cover the entire course of treatment for my present condition and for any future conditions for which I seek treatment.
As of June 1, 2018, we can bill BlueCross Extended Health.
Please provide the primary policy holders name: _____________________________________
Relation to policy holder (self, spouse, child): ________________________________________
Please provide your Policy/Plan Number: ___________________________________________
Please provide your ID Number: __________________________________________________
Electronic Transmission Authorization
Please check if you give Abbotsford Sports and Orthopaedic Physiotherapy permission to electronically submit claims for your Physiotherapy/Massage treatments to your insurer.
Assignment of Benefits
Please check if you give Abbotsford Sports and Orthopaedic Physiotherapy permission to collect claim payments for your Physiotherapy/Massage treatments from your insurer.
Unit 308 – 32625 South Fraser Way Abbotsford, BC V2T 1X8Abbotsford Sports &
Orthopaedic Physiotherapy
Cancellation and No-Show Office Policy
To provide efficient services to all our patients, we strictly enforce a fee for any late, missed, or cancelled appointment (less than 24 hours). This ensures that we can provide quality, timely services to all patients as efficiently as possible.
As a courtesy we offer to send appointment reminders by text or by email. You however are still responsible for informing us if you are unable to attend. This must be done within a 24-hour timeframe during regular business hours with one of our staff members by phone call only. We are unable to accept such requests via voicemail, email or text message.
The no show fee is 50-100 percent of the treatment fee depending on the service booked.
All appointments will end at the scheduled time so that we may serve the next patient at their scheduled start time. Late comers may be required to reschedule for a later time or another day and an appropriate charge for the late or missed appointment will apply.
Please note all fees incurred must be paid before your next scheduled appointment and cannot be waived by the front desk staff members.
Patients are to email the management at [email protected] should any questions or concerns arise.
Thank you from all the Professionals and staff at Abbotsford Sports & Orthopaedic Physiotherapy Clinic
