Physiotherapy Intake & Waiver

Please fill out this form below, reading all information carefully before submitting. Please note that all fields marked with an asterisk are required fields.

  • MM slash DD slash YYYY
  • If not here for an injury, tell us about what you wish to accomplish during your visit.
  • MM slash DD slash YYYY
  • Including Diabetes, High Blood Pressure, Cancer, etc.
  • Declaration

    I certify that the above medication information is correct to my knowledge.

    Privacy – I authorize Scienced Athletics and its associated health professionals to collect my personal and medical information as documented above. In addition, I authorize the communications with my family doctor and/or referring practitioners as deemed necessary for my beneficial treatment. I also understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission.

    Cancellation Policy – Your appointment time is reserved just for you. A late cancellation or missed visit leaves a gap in the therapist’s day that could have been filled by another patient. As such, we require 24 hours’ notice for any cancellations or changes to your appointment. Patients who provide less than 24 hours’ notice, or miss their appointment, will be charged a cancellation fee of the full amount of the appointment.

    Acknowledgement & Consent – I fully consent to treatment at Scienced Athletics. I appreciate there can be no guarantee or assurance as to results and that further treatment may be necessary. I do expect the practitioner, based on the facts known to them, will work with me in my best interest. I also understand I will be informed by the practitioner towards any potential risks associated with my treatment, as well as potential benefits for treating my condition. My consent may be withdrawn at any time I notify my practitioner. I also understand that discontinuation of the treatment(s) without consult my physician or practitioner may result in worsening of my condition.

    Benefits / Extended Health – I acknowledge that I am responsible for understanding my extended health benefits and coverage. When claiming appointments through insurance, I will take the responsibility of making sure services I claim for are accurately submitted based on the receipt to my best ability.

    If the patient is under 18 years of age: I, the parent/guardian of the minor Patient, fully consent to the practitioner working with my child. I understand the treatment and procedure.