Patient Information Date:

First Name: Surname:

Address: suite/apartment#:

City: Postal Code:

Home Phone#: Mobile #: Email Address:

OHIP card #: Version Code:

Sex: M F Date of Birth (mm/dd/yyyy): / /

Name of Emergency Contact: Relationship: Home Phone: Work Phone:

( ) ( )

Employer Information

Name of Employer:

Address:

City: Postal Code:

Business Phone#:

Occupation:

Insurance Information

Do you have Private Insurance? Yes No

If yes please fill in the following section.

Consent to check for Insurance Coverage? Yes No

Insurance Name:

Address:

Phone # Fax #

Policy # Group #

ID. # Plan #

If you are covered under someone else please fill in the following:

Name of Insured: DOB of Insured (mm/dd/yyyy): / /

Referring Physician Information

Phone # Fax #

Doctors Name:

Address:

Refusal to Disclose Insurance Information

I, , do not wish to disclose my extended health care benefits insurance information to Novo Healthnet Limited.

I am aware that the reason for this request is to keep track of my coverage and agree that I will personally keep track and be responsible for my account.

(Patient Signature) (Administrator Signature)

(Date) (Date)

Novo Healthnet Limited

REHABILITATION AND WELLNESS DIVISION

PHYSIOTHERAPIST, REHABILITATION and MASSAGE THERAPIST INFORMED CONSENT

As a matter of ethics and law there is an obligation, prior to examination and treatment, to disclose any material risk to the patient in order to obtain a valid informed

consent. As part of the physiotherapy, chiropractic and massage treatments, certain procedures and devices may be utilized such as the use of heat, ice,

electrotherapy, ultrasound, massage and manual therapy. As part of the rehabilitation program (kinesiologist, occupational therapist or physical therapist assistant)

certain testing procedures, devices and equipment may be utilized such as weight machines, exercise, cardiovascular work and functional tasks. I have had the

opportunity to discuss with the doctor of chiropractic/physiotherapist and/or other clinical staff, the nature and purpose of treatments. I understand the results are not

guaranteed. I further understand and I am informed that there are some very slight risks to treatments, including, but not limited to, muscle strains, sprains, disc

injuries, and burns have been made aware that there are remote chances of injury and that appropriate tests will be performed to help identify if I may be susceptible

to risk or injury. I have read and understood the above statement, accept the risk and hereby consent to treatment.

Patient Signature: Date:

Parent/Guardian Signature: Date:

Witness Signature: Date:

CHIROPRACTIC INFORMED CONSENT (FORM L)

There are risks and possible risks associated with manual therapy techniques used by doctors of chiropractic. In particular you should note:

a) While rare, some patients may experience short term aggravation of symptoms or muscle and ligament strains or sprains as a result of manual therapy techniques.

Although uncommon, rib fractures have also been known to occur following certain manual therapy procedures;

b) There are reported cases of stroke associated with visits to medical doctors and chiropractors. Research and scientific evidence does not establish a cause and

effect relationship between chiropractic treatment and the occurrence of stroke. Recent studies suggest that patients may be consulting medical doctors and

chiropractors when they are in the early stages of a stroke. In essence, there is a stroke already in progress. However, you are being informed of this reported

association because a stroke may cause serious neurological impairment or even death. The possibility of such injuries occurring in association with upper cervical

adjustment is extremely remote;

c) There are rare reported cases of disc injuries identified following cervical and lumbar spinal adjustment, although no scientific evidence has demonstrated

such injuries are caused, or may be caused, by spinal adjustments or other chiropractic treatment;

d) There are infrequent reported cases of burns or skin irritation in association with the use of some types of electrical therapy offered by some doctors of

chiropractic.

I acknowledge I have read this consent and I have discussed, or have been offered the opportunity to discuss, with my chiropractor the nature and purpose of chiropractic treatment in general, (including spinal adjustment), the treatment options and recommendations for my condition, and the contents of this Consent.

I consent to the chiropractic treatment recommended to me by my chiropractor including any recommended spinal adjustments.

I intend this consent to apply to all my present and future chiropractic care.

Patient Signature: Date:

Parent/Guardian Signature: Date:

Witness Signature: Date:____ _____ ____ _____

CONSENT AND AUTHORIZATION FOR RELEASE/LOAN OF MEDICAL INFORMATION/DIAGNOSTIC MATERIAL

I, do hereby give my written permission and authorization to Novo Healthnet Limited to communicate on my behalf, release and share information regarding my health and progress, for the purpose of determining my functional abilities for developing and implementing a functional rehabilitation program.

I give permission to the following to provide and receive information pertaining to my medical condition.

This consent may be revoked in writing at any time. Any such revocation shall have no effect on disclosures made prior to the date of revocation is received. I UNDERSTAND THAT I HAVE THE RIGHT TO INSPECT AND COPY THE INFORMATION TO BE DISCLOSED.

Patient Signature: _ _ Date:

Parent/Guardian Signature:

Date:____ _____ ____ _________ _____

Witness Signature:

Date:

PATIENT CONSENT TO RELEASE PERSONAL HEALTH INFORMATION

I consent Novo Healthnet to release the following information to the Ministry of Health and Long- Term Care (“Ministry”) as of the date indicated below:

Patient Information: (Please Print)

1. Last Name: First Name: Middle Name:

2. Date of Birth:

(YYYY-MM-DD)

3. My Ontario Health Card Number:

4. A description of the physiotherapy service(s) provided to me by physiotherapy providers at

my physiotherapy clinic as of the date indicated below, and

5. The date(s) on which these service(s) are provided to me.

I understand that I can withdraw my consent by contacting the Novo Healthnet at (416)298-0474 and that if I

withdraw my consent I will be required to pay the Clinic directly for services that the Clinic provides to me as a patient following the withdrawal of consent.

Patient Signature:

I am signing on my behalf

I am signing as a parent, or person who is lawfully entitled to give or refuse consent, on behalf of a child who is under 16

I am signing as the guardian of the person, or attorney for personal care of an incapable

adult

Name: (please print)

Signature: Date: (YYYY-MM-DD)

Please provide your contact telephone number if you are signing on behalf of a child, or an

Incapable adult:

Informed Consent Form for Therapy Treatment

of a Minor (under 18 years of age)

Patient Information

First Name: Surname:

Address:

City: Postal Code:

Home Phone#: Mobile #: Email Address:

Sex: M F Date of Birth (mm/dd/yyyy): / /

Name of Emergency Contact: Relationship: Home Phone: Work Phone: ( ) ( )

Parent/Guardian Information

First Name: Surname:

Address:

City: Postal Code:

Home Phone#: Mobile #: Email Address:

Sex: M F Date of Birth (mm/dd/yyyy): / /

Relationship to Patient: Home Phone: Work Phone: ( ) ( )

Parent/Guardian Signature Date

Witness Date

OHIP Funded Physiotherapy Patients: Dear Patient,

As you are applying for an Episode of Care (EOC) under the OHIP funded Physiotherapy program, we would like you to be aware of a few changes as of August 1st, 2013:

Under the new model you will receive:

• Treatment for specific conditions or diagnosis

• Time- limited, goal- oriented care

• Education

• Home exercise programs

The new Ministry model does NOT cover:

• Treatment to maintain an existing level of function, or

• Physiotherapy treatment, at the same time for an injury that is funded by another source (i.e.: Worker’s compensation, CCAC, motor vehicle accident benefits, or private health insurance plans.)

If you have any questions or concerns, please do not hesitate to ask our staff.

EOC Funding Agreement: I, ________________________________ understand that Novo Healthnet Limited will submit to the Ministry of Health, invoices related to treatment received at the clinic and I agree to provide Novo Healthnet Limited will all necessary documents and information. I understand that physiotherapy funding is not covered, if there is, at the same time, coverage for an injury that is funded by another source (i.e.: Worker’s compensation, CCAC, motor vehicle accident benefits, or private health insurance plans.) In the event that the Ministry of Health refuses to make the payments for my treatments to Novo Healthnet Limited, I agree that I shall pay to Novo Healthnet Limited including the costs of such treatment.

_______________________________ ________________________ Patient’s Signature Date

_______________________________ ________________________ Witness Signature Date

Cancellation and Missed Appointments Policy 病人取消戓缺席之條款

• Please give 24 hours advance notice for cancellation of appointments as the Physiotherapist reserves the time and equipment for you. Failure to give 24 hours notice will be treated as missed appointments.

如要取消或更改物理治療的時間或日期, 請於24 小時前通知本中心, 否則當作缺席。

• Automatic Discharge will result if 3 appointments or more sessions are missed within one Episode of Care regardless of any reason. $30 will be charged to re-activate your file.

無論是任何原因, 凡病者在整個療程裏缺席三次或以上, 病者之所有的療程將會自動取消。若病者要

求再繼續療程, 必須繳交 $30 元作為重新辦理檔案之費用。

• Any patients who late for more than 10 minutes may be asked to give up the modality treatment to avoid backlog of the booking. They will receive only part of the treatment if feasible or have the appointment rescheduled. If the appointment needed to be rescheduled, it will also be counted as missed appointment.

凡病者遲到超過10 分鐘, 以免影響其他輪侯病者的治療時間,物理治療師在情況許可下酌情為遲到病

者安排其他或部份的治療。若不能安排治療或病者拒絶安排, 這次預約時間將當作取消, 病者需要再

叧行預約時間。 而這次應診將作缺席計算。

• If a patient is unable to participate in Physio for 4 weeks or more, This Episode of Care will be discharged and a new assessment and new referral will be necessary in order to continue therapy.

如果病者在整個療程中缺席4週或以上，整個療程會被終止。如病者需要繼續治療, 病者必須由醫生

再轉介, 重新登記及評估。

_________________________ _________________________ Name (Print) Signature

_____________________

Date