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.

Full Name*
First Last
Physiotherapist*
Your Phone Number*
Your Email Address*
Your Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Gender / Sex*
Date of Birth*
MM slash DD slash YYYY
Emergency Contact Name*
Emergency Contact Relationship*
Emergency Contact Phone
Height
Weight
Occupation
Referred by...
Name of Family Doctor / Clinic
Reason For Your Visit
If not here for an injury, tell us about what you wish to accomplish during your visit.
How the Injury Occurred
Date of Injury
MM slash DD slash YYYY
What Makes It Better?
What Makes It Worse?
Have You Seen Another Practitioner or Had Treatments for this Injury?
Have You Had Imaging (CT Scan, MRI, X-Ray)? Include When
Please Detail Any Current or Past Medical Conditions
Including Diabetes, High Blood Pressure, Cancer, etc.
Please List Any Current Prescriptions or Medications You Are Taking
Please List Any Previous Injuries and Surgeries with Dates
How Often Do You Exercise? At What Intensity?
List Any Goals, Activities, Sports, or Hobbies You Would Like To Return To
Is this an ICBC or WorkSafe BC Claim?
- Yes
- No
- Unsure
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.
Consent*
I have read all information above and consent to submitting my information.*

Physiotherapy Intake & Waiver

Declaration