Intake forms | Sandalwood Physiotherapy & Wellness

Welcome to Sandalwood Physiotherapy & Wellness! In order to serve you better, please take a moment to complete this form. If you require assistance, please ask the receptionist. When finished, kindly return this form to the front desk.

Today's Date(Required)

How did you hear about us?(Required)

If referred, please print the name

Patient's Name(Required)

Date of birth(Required)

Gender

Address(Required)

Street Address City ZIP / Postal Code

Home Phone(Required)

Cell Phone(Required)

Work Phone

Employer

Occupation

Email(Required)

Insurance Company

Policy/Contact

ID/Certificate

Please fill the following if policu holder is not same as the patient mentioned or select policy holder same as

Policy Holder's Name

Date of Birth

Relationship

Secondary Insurance Company

Policy / Contract

ID / Certificate

Policy Holder's Name

Date of Birth

Relationship

Case Information: Please Indicate the reason for your visit and complete the related information

Automobile Accident: Date of Accident(Required)

Claim No(Required)

MVA Adjustor Name(Required)

Adjustor's email(Required)

Legal Representative(Required)

Lawyer's Contact No(Required)

Insurance company(Required)

Policy No(Required)

Phone no(Required)

Adjustor's Fax No(Required)

Work Injury

Date of Accident(Required)

Claim No(Required)

PATIENT’S CONSENT – PLEASE READ CAREFULLY BEFORE SIGNING

This is to inform that I, undersigned, that all of the above personal and insurance information is true to my knowledge and I have not omitted any pertinent information. I will assume responsibility for fees associated with paramedical services and / or medical supplies received by me and payment plan was discussed with me in details. I also authorize Sandalwood Physiotherapy & Wellness Clinic staff to obtain required medical information from my family physician and extended health coverage from my insurance company.

PAYMENT AGREEMENT

I understand and agree that health insurance policy is an arrangement between an insurance carrier and myself. I understand that Sandalwood Physiotherapy & Wellness Clinic will prepare necessary reports and forms to assist me in making collection from insurance company and that any amount authorized to be paid directly to this office will be credited to my account on receipt. I understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I will be also responsible for the payments to the services rendered after the expiration / termination of my or my family’s health insurance coverage. I will inform Sandalwood Physiotherapy & Wellness Clinic personnel immediately upon knowing any changes to my insurance policy. If the cheque from insurance comes to me and I have not paid for the treatment, I will immediately hand over the cheque to Sandalwood Physiotherapy & Wellness Clinic. I understand and agree that this office, as courtesy to me, will not impose any interest charges to any balance that I may occur for a period of thirty days after the charges are occurred, to afford my insurance carrier, if any, that amount of time to make payment. It is understood that any balances outstanding for more than thirty days will be charged interest at the rate of 1.5 percent per month and I agree to pay said charges. In the event my account balance referred to an agency or attorneys for collection purposes, I agree to pay reasonable attorney’s fees and any expenses or costs relating to the collection proceeding, including court costs. In the event that patient is minor, I am the parent and / or legal guardian or said patient and agree that I am responsible for all services rendered to the patient herein. I understand that if I suspend or terminate my care and treatment, any fees for professional services rendered to me will be immediately due and payable.

Signature(Patient/Parent/Guardian)(Required)

Date

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