Monterey Park Physiotherapy Clinic | Best Physio in Calgary

Patient Information

First Name *

Last Name *

Date of Birth (dd/mm/yy) *

AHS No.

Postal Code

Home Phone No.

Address

Cell Phone No.

Work Phone No.

Gender

Email *

Emergency Contact Name

Emergency Contact Relation

Emergency Contact No.

Extended Health Care Benefits / Insurance Information

Coverage Type

Name of the Insurance

Policy No. & Member ID No.

Claim No.

Date Of Loss (dd/mm/yy)

Coverage

Primary / Secondary

Claims Representative (If Applicable)

Claims Representative's Email

Claims Representative's No.

Physician Information

Physician's Name

Clinic

Address

Phone No.

How did you hear about us?

Referral Source

Medical History

1. Do you currently have or have you previously had any of the following conditions?

Allergies

Other (please specify)

2. Have you had any surgeries? Please provide detail:

3. List of current medication:

4. Are you pregnant?

Treatment Information and Consent

Physiotherapy techniques may include manual techniques (spinal manipulation), electrotherapeutic modalities (shockwave therapy, laser), exercise prescription, acupuncture/IMS/dry needling. These techniques may be recommended during treatment sessions. Patient participation is crucial for success.

It is the policy of Monterey Park Physiotherapy to explain benefits, side effects, and potential complications of each chosen modality. Patients must inform their therapist immediately if they choose not to participate in any part of the program.

I understand and agree with the criteria above and as such agree to participate in an assessment and treatment program at Monterey Park Physiotherapy. I understand that for the duration of my treatment, my consent may be withdrawn at any time and understand that I must inform my physiotherapist.

Signature (Patient/Guardian)

Date

Signature (Witness)

Date

Release of Medical Record

I authorize Monterey Park Physiotherapy to release or request any information from Physicians, Diagnostic Centers, Insurance Companies, Employers, and Law Firms with respect to my care.

Signature (Patient/Guardian)

Date

Acknowledgement and Cancellation Policy

Patients are responsible for providing 24 hours' notice for appointment cancellations. If you cancel without notice, there will be a $30 cancellation fee.

I acknowledge that if I do not provide 24 hours' notice, I may be charged a cancellation fee.

I also acknowledge that third-party funders may not pay for cancellation charges I may incur, and that I may be personally responsible for paying such cancellation charges.

Signature (Patient/Guardian)

Date

Billing and Payment

I authorize Monterey Park Physiotherapy to submit claims on my behalf to my insurance company and I am responsible to pay any co-payment or any outstanding balance for services at each time of the appointment upon arrival. In the event my insurance company denies the payment for any reason, I would be solely responsible to pay for my services. If the client does not carry any insurance coverage, then the client is fully responsible to pay the complete fee amount for his/her Physiotherapy services at each time of appointment upon arrival.

For MVA, inside protocol (within 90 days of accident), Clinician/Clinic may provide and claim for two treatment visits on the same day while treating multiple body parts during a single attendance at the practice setting. Clinic clearly communicates applicable fees to clients and payors prior to the provision of services. Client may ultimately attend the practice setting less than the number of visits allocated in the DTPR, due to the use of multiple treatment visits during a single attendance.

Signature (Patient/Guardian)

Date

Patient Intake Form

Patient Information

Extended Health Care Benefits / Insurance Information

Physician Information

How did you hear about us?

Medical History

Treatment Information and Consent

Release of Medical Record

Acknowledgement and Cancellation Policy

Billing and Payment