Patient Intake Form

Now we are open on weekends – Book your appointment

Emergency Contact Name/Relation

Emergency Contact No.

Extended Health Care Benefits/Insurance Information

Private Insurance (Manulife, Green shield etc.) MVA WCB Self Pay

Name of the Insurance

Policy No. & Member ID No.

Claims Representative (If Applicable)

Claims Representative’s Email

Claims Representative’s No.

Physician Information

How did you hear about us?

Internet Physician Friend /Relative Other

Do you Currently have or previously had any of the following conditions?

Have you had any surgeries? Please provide detail

List of current medication

Are you pregnant?

YES NO

If yes, please note any and relevant details

Release of Medical Record

Acknowledgement and Cancellation policy

Billing and Payment

Treatment Information and Consent

Calgary’s most trusted Physiotherapy, Massage Therapy and Pelvic Health Clinic. We offer many services including physiotherapy, manual therapy, registered massage therapy, vestibular therapy,dry needling physiotherapy, custom foot orthotics, shockwave therapy and more. Our locations are conveniently located in Country Village and Monterey Park.

Direct Billing

We offer direct billing service. Please contact our office for more details.

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Direct Billing

PHYSIOTHERAPY SERVICES:

RESOURCES:

Our Locations