Professional Physiotherapy  & Sports Clinic

New Patient Intake Form

Professional Physiotherapy and Sports Clinic

Please note ,if you are a returning patient you don't need to fill this form. Please call the front desk and book appointment at your convenience. Thank you.

Please note this will be the primary number to contact in case of an emergency/cancellations by the clinic. The clinic will make two attempts to reach you. You may provide an alternate number to reach you. Please let the front desk know if you prefer a different way to communicate for unexpected clinic closures. Thank you for understanding.

Please write your name on the line below then check the following boxes:

Please print your name

Client authorization for Disclosure of Information:

Hereby authorize Professional Physiotherapy and Sports Clinic to obtain and/or release information regarding my treatment progress, functional abilities and return to work/activity to all the following parties listed below
Consent to treatment:
Physiotherapy treatments may include, but are not limited to the following: an assessment, manual (hands on) treatment, modalities for pain/swelling/healing, acupuncture, traction and exercise/stretching. Kinesiology sessions may include, but are not limited to an assessment and prescription or modification of exercise and stretching. I consent to the treatments offered or recommended to me by my Physiotherapist/Kinesiologist. I understand the following regarding billing: Professional Physiotherapy and Sports Clinic is not an OHIP funded clinic, that means  you are responsible for full payment of your account. Your payment options are as follows:
  • We accept payments after each visit.We accept Mastercard, Visa, Debit, Cheque or cash
  • Direct Billing:
Please call us to provide your  health insurance plan number and details, our insurance team will contact your insurance provider. Please click the New Patient tab,and fill in your details online and we will call you back.  we will let you know if you are covered for Physio through your existing policy. Please note we are not set up to direct bill all insurance companies but will do our best to accommodate your needs.
  • If your claim cannot be processed online, you are responsible to pay after each visit. Please print your name below if you read this :
Cancellation and No Show Policy
We understand that unplanned issues can arise and that you may need to cancel an appointment. If that happens, we respectfully ask for scheduled appointments to be cancelled at least 24 hours in advance.When you do not come to your scheduled appointment it affects three people: YOU because you don't get the treatment you need to get better . The THERAPIST who now has a empty space in his schedule since the time was reserved for you personally.ANOTHER PATIENT, who is in need of treatment, could have been scheduled for treatment if you had given us adequate notice. There is a no show/cancellation fee of $45 for Physiotherapy visits and $25 for other services if we do not receive a phone call with 24 hours’ notice. This charge will not be covered by insurance, it will have to be paid by you personally. For Worker's Compensation and Motor Vehicle Injury patients, documentation of any missed appointments may be requested by your Case Manager, which could adversely affect your claim.  
For Worker's Compensation and Motor Vehicle Injury patients, documentation of any missed appointments may be requested by your Case Manager, which could adversely affect your claim.
It is your responsibility, when you contact us to cancel your appointment, to have an alternative time in mind that will ensure you get the full treatment for that week. In some cases this may not be possible, but we will make every effort to accommodate your reschedule request.Please understand that you may need to be seen by a different therapist than the one that normally treats you, if you reschedule your appointment. All of our therapists are experienced professionals, and they will review your chart, so you will be in good hands and taken care of. Thank you for being a valued patient and for your understanding and cooperation.This policy will enable us to better serve the needs of all patients including yourself.
Please understand that you may need to be seen by a different therapist than the one that normally treats you, if you reschedule your appointment. All of our therapists are experienced professionals, and they will review your chart, so you will be in good hands and taken care of.