PERSONAL INFORMATION
NAME:
LAST FIRST MIDDLE INITIAL
HOME ADDRESS:
CITY: POSTAL CODE:
BUSINESS PHONE: RES. PHONE:
DATE OF BIRTH: AB HEALTH CARE NUMBER:
OCCUPATION: EMAIL:
MALE □ FEMALE □ MARITAL STATUS: M □ S □ W □ D □ DATE OF INJURY:
PHYSICIAN...
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PERSONAL INFORMATION
NAME:
LAST FIRST MIDDLE INITIAL
HOME ADDRESS:
CITY: POSTAL CODE:
BUSINESS PHONE: RES. PHONE:
DATE OF BIRTH: AB HEALTH CARE NUMBER:
OCCUPATION: EMAIL:
MALE □ FEMALE □ MARITAL STATUS: M □ S □ W □ D □ DATE OF INJURY:
PHYSICIAN NAME AND ADDRESS:
In the interest of inter-professional communication, we will be in touch with your Physician regarding the care you receive
at our off. If you DO NOT wish us to contact your Physician, please initial here:
DO YOU HAVE EXTENDED HEALTH INSURANCE THROUGH WORK OR SPOUSE? YES NO
PLEASE NOTE THAT WE DO NOT ACCEPT WCB CASES.
HOW DID YOU HEAR ABOUT THIS CLINIC?:
FEES FOR PHYSIOTHERAPY TREATMENT:
INITIAL CONSULTATION $110.00
NEW AREA $110.00
TREATMENT $ 80.00
There will be an $80.00 fee for any cancellation given with less than 4 hours notice, and a $ 40 fee for any
cancellation given less than 24 hours notice.
Re-examination are done in the event of a 2 month lapse between office visits.
Should your insurance carr
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