Email Address *

Last Name *
First Name *
Middle Initial *
Birth Date *

MaleFemale
Gender *
Age *
AHC#
Family Physician (first initial & surname)

Home Address *

City *
Province *
Postal Code *

Home Phone *
WCB Claim # *
Incident Date *

Employer Information

Job Title/Occupation *
Company Name *

Address: *

City: *
Province *
Postal Code *
Phone No. *

Medical Information

Which practitioner or facility rendered first treatment

Date

Have you had previous physiotherapy in the past year?

If yes, where and when:

Were you referred to Bonavista Physical Therapy?

If yes, by whom?

If no, how did you hear of us?

Physiotherapists practice within a code of ethics, and a privacy policy is in place.

• In case of an emergency in this office, your therapist or another staff member will inform you of evacuation procedures.

• I understand that I am able to decline treatment at any time.

• I am aware that there is a grievance procedure and that I can appeal decisions regarding my care in case I am not satisfied with the service.

• I will allow Bonavista Physical Therapy Clinic to communicate with my physician, my radiologist, the Worker’s Compensation Board and my employer regarding my condition.

• I understand that if Worker’s Compensation Board does not accept responsibility for the claim, I will be responsible for the cost of treatment.

• I have provided a VISA or MC draft as insurance in the case my claim is not accepted.

I acknowledge and understand the above information