New Client Form Step 1 of 4 25% Name* First Last Gender* Male Female Preferred pronouns Birth Date* MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email Address for reminders* Cell Phone*PhoneHome PhoneArea Treated* How did you hear about us?* What type of therapy do you need?* Physiotherapy Massage Therapy Both (Physiotherapy & Massage) Athletic Therapy Referring Doctor/Family Doctor Emergency Contact Name Emergency PhoneAppointment day or time requests/comments: AUTHORIZATION FOR TREATMENT/BILLING I, THE UNDERSIGNED authorize KENASTON COMMON PHYSIOTHERAPY to commence treatment. I understand that I am responsible for any treatment costs incurred and that payment is required at the time of each treatment. Payment can be made by Cash, Cheque, Debit, Visa or Mastercard. If direct billing is being done on my behalf to an insurance company, I authorize the use of my personal information (and my spouse when applicable) for this purpose. Such communication may be electronic. Patients who are covered under the Workers Compensation Board/Manitoba Public Insurance, Department of Veterans Affairs and the Department of National Defense will not receive any statement or pay any costs unless there is difficulty or delay in collecting payment from the applicable agency, at which time you will be responsible for payment. Patients who are covered under private insurance will be responsible for payment of their portion prior to each treatment session. IT IS THE PATIENTS RESPONSIBILITY TO KNOW THEIR HEALTH INSURANCE COVERAGE. ANY FEES NOT PAID BY THE INSURER ARE THE PATIENTS RESPONSIBILITY. All OVERDUE ACCOUNTS ARE SUBJECT TO INTEREST CHARGES. I am aware of the policy that if I miss an appointment or cancel in less than 24 hours, I will be charged a $40 non- attendance fee.* Yes No WCB CLAIM # (if applicable) MPI CLAIM # (if applicable) Insurance Company (if applicable) Contract ID or Policy Number 1 Contract ID or Policy Number 2 Primary Policy Holder Name In order to save time for your first appointment, please fill up the PDF forms below. Massage Therapy Health Form Massage Therapy Pain Diagram Save the above PDF on your computer (including your changes) You can either upload both PDF back right here using the upload tool below or email them prior to your appointment at messagekcphysio@shaw.ca File uploadMax. file size: 512 MB.Second fileMax. file size: 512 MB. Δ
