Consent Form with Satisfaction Survey

Personal Information

Name*

First Last

Date of Birth (yyyy-mm-dd)*

Address*

Date of Injury / Onset of Pain*

Area Being Treated*

Email*

Cell Phone #*

Home Phone #

Work Phone #

Family Physician

Occupation

Employer

Emergency Contact*

Emergency Contact Phone #*

Email Notification

I would like to receive email notification of my upcoming physiotherapy appointments.

Email Notification

I would like to receive text message notification of my upcoming physiotherapy appointments day of.

Survey

I would be willing to participate in a short patient satisfaction survey

Funding Information

I will pay

I will pay for the cost of my assessment / treatments.

Private Insurance

Please directly bill my private health insurance

Name of Insurance Plan

Policy Holders DOB

Policy/Contract #

Member ID #

Work Injury test

I have been injured at work. Please directly bill Worksafe BC.

Claim #

WSBC Case Manager

Motor Injury

I have been injured in a Motor Vehicle Collision. Please directly bill ICBC. I will pay the user fee.

ICBC Claim #

Lawyer

ICBC Adjuster

Lawyer's Phone #

ICBC Adjuster's Phone #

I am covered by MSP Premium Assistance

My income level is low enough that I qualify for MSP Supplementary Benefits. Please directly bill MSP and I will pay the user fee.

MSP Health Care Card #*

CONSENT TO RELEASE INFORMATION
I consent to the staff at Long Lake Physiotherapy gathering diagnostic information and medical reports in order to assist with treatment of my condition. I also consent to the release of information within my clinical chart to the following parties:

Consent Checkboxes

Physician
ICBC
WorkSafe BC
Employer
Lawyer
Insurance

PAYMENT & CANCELLATION POLICY*

I understand that payment for services is my responsibility and due immediately upon receipt of the treatment. If my treatment costs are being billed to another party and for some reason the claim is denied in full or in part, I am responsible for the amount outstanding. I understand that unless I provide 24 hours notice to cancel an appointment, I will be charged for the appointment.

CONSENT TO TREATMENT*

I authorize the physiotherapists at Long Lake Physiotherapy to assess and treat as appropriate the condition for which I am here today. Physiotherapy treatment may include manual therapy (including manipulation), Intramuscular Stimulation (IMS), acupuncture, electrotherapeutic modalities, exercise, as well as other techniques. If at any time I choose not to consent to treatment, I will inform my physiotherapist immediately.

Signature*

Date*

Consent Form with Satisfaction Survey

Title