Please fill in the following client information questionnaire to the best of your ability.  Please note that all of your information is kept in the strictest of confidence in compliance with federal and provincial privacy legislation and applicable college regulations.  Please take a moment to review Resolution Physiotherapy & IMS Clinic's privacy policy here PRIVACY POLICY.  If you would like a paper copy of our policy or have any questions regarding our privacy policy, please contact our Health Information Custodian, Mandi Hayes at 705-252-5200 or mandihayes@resolutionclinic.com.  We thank you for taking the time to fill in this documentation. 

Question Title

* 1. Client

Question Title

* 3. Contact Info

By providing your email address, you are consenting to receive email appointment reminders, responses to any emails you send to us, and customer satisfaction surveys from Resolution Physiotherapy & IMS Clinic. If you would prefer NOT to receive any of the above, please contact us and we will happily comply with your request.

Question Title

* 4. Do you have extended benefits coverage?

DIRECT BILLING TO EXTENDED BENEFITS PLANS
At Resolution Physiotherapy & IMS Clinic we are able to bill directly to most extended medical plans.  Please provide us with extended medical information for you and your spouse and we will determine if your insurance company allows for direct billing.

Question Title

* 5. Insurance/Benefits (if applicable)

The following is a requirement of extended benefits plans where you authorize Resolution Physiotherapy & IMS clinic to bill electronically on your behalf and authorize for payment to come directly to Resolution Physiotherapy & IMS Clinic.  

Question Title

* 6. BENEFIT ASSIGNMENT
I hereby assign benefits payable for the eligible claims to Resolution Physiotherapy & IMS clinic who will be submitting my claims electronically to the group benefits plan and I authorize the insurer/plan administrator to issue payment directly to Resolution Physiotherapy & IMS Clinic. In the event my claim(s) are declined by the insurer/plan administrator, I understand that I remain responsible for payment to Resolution Physiotherapy & IMS Clinic for any services rendered and/ or supplies provided. 

I acknowledge and agree that the insurer/plan administrator is under no obligation to accept this Assignment, that any benefit payment made in accordance with this Assignment will discharge the insurer/plan administrator of its obligations with respect to that benefit payment, and that in the event the benefit payment is made to me, the insurer/plan administrator will also be discharged of its obligation with respect to that benefit payment. 

I understand that this Assignment will apply to all eligible claims submitted electronically by Resolution Physiotherapy & IMS Clinic and that I may revoke it at any time by providing written notice to the insurer/plan administrator. 

If I am a spouse or dependent, I confirm that I am authorized by the plan member to execute an assignment of benefit payments to the Provider.

Question Title

* 7. ELECTRONIC TRANSMISSION AUTHORIZATION & CONSENT FORM

Consent to Collect and Exchange Personal Information 

Message to the Plan member, Spouse and/or Dependent regarding Personal Information 

Personal information that we collect and disclose about you, and if applicable, your spouse and/or dependents, is used by the insurer and/or plan administrator and their service provider(s) for the purposes of assessing your claims, underwriting, investigating, auditing and administering the group benefits plan, including the investigation of fraud and / or plan abuse. 

Authorization and Consent 

I authorize my healthcare provider to collect, use and disclose personal information concerning any claims submitted on my behalf with the insurer and/or plan administrator and their service provider(s) for the above purposes. 

I authorize the insurer and / or plan administrator and their service provider(s) to: 
  • use my personal information for the above purposes.
  • exchange personal information with any individual or organization, including healthcare professionals, investigative agencies, insurers and reinsurers, and administrators of government benefits or other benefits programs when relevant for the above purposes.
  • exchange personal information concerning any claims submitted with the plan member or a person acting on behalf of the plan member.
  • exchange personal information for the above purposes electronically or in any other manner. 

I understand that personal information may be subject to disclosure to those authorized under applicable law. 

I agree that an electronic version of this authorization shall be as valid as the original, and may remain in effect for the continued administration of the group benefits plan. 

Additional Consent Applicable to Plan Members Only 

I confirm that I am authorized by my spouse and/or dependents, if any, to disclose personal information about them to the insurer and/or plan administrator and their service provider(s) for the purposes described above and I confirm that my spouse and/or dependents also authorize the insurer and/or plan administrator and their service provider(s) to disclose information about their claims to me, for the purposes of assessing and paying a benefit, if any, and managing the group benefits plan. I also authorize my spouse and/or dependents to assign benefit payments under the plan to the healthcare provider. 

In the event there is suspicion and/or evidence of fraud and/or plan abuse concerning claims submitted, I acknowledge and agree that the insurer and/or plan administrator and their service provider(s) may use and disclose relevant personal information to any relevant organization including law enforcement bodies, regulatory bodies, government organizations, medical suppliers and other insurers, and where applicable my Plan Sponsor, for the purposes of investigation and prevention of fraud and/or plan abuse. 

If there is an overpayment, I authorize the recovery of the full amount of the overpayment from any amount payable under the group benefits plan, and the exchange of personal information with other persons or organizations, including credit agencies and, where applicable, my Plan Sponsor, for that purpose.

Question Title

* 8. How did you hear about us?

Question Title

* 9. If you found us through a web search, what key words did you use to find our website?

Question Title

* 10. Do you have a family doctor?

Question Title

* 11. Family Physician

Question Title

* 12. Family Dentist (if referred for TMJ (jaw) pain)

Question Title

* 13. Health History.
Please check the box if you have, or have had any of the following medical conditions:

Question Title

* 14. Health conditions screened for in Question 8 (for reference only): 
Cancer, Diabetes, Seizure Disorder, Asthma, Heart Condition, Angina, Pacemaker, High BP, PVD, Stroke, TIA, Bleeding Disorder, HIV, TB, Blood borne condition, OP, Osteopenia, Neurological condition, Headaches, Incontinence, Depression, Currently Pregnant, & Other.

Question Title

* 15. Please take a moment to click on and read our 'Informed Consent for Physiotherapy Assessment, Treatment, & Billing' and 'Privacy Policy' documents.

By typing my name and today's date below:

I consent that I have reviewed Resolution Physiotherapy & IMS Clinic's "Privacy Policy" and "Informed Consent for Physiotherapy Assessment, Treatment, and Billing" and that I consent to receive Physiotherapy assessment and treatment at Resolution Physiotherapy & IMS Clinic.

I understand that payment for physiotherapy services are my responsibility and are to be paid at each visit, and I will be charged $150.00 for initial assessments, and $75.00 for follow up treatments.  While all efforts will be made to bill directly to insurance plans (ie. Extended health benefits or MVA insurance company), if a third party payer denies or partially pays the amount billed, I am responsible for paying any outstanding balance.

I understand that Resolution Physiotherapy & IMS Clinic requires 24 hours notice to cancel a scheduled appointment and that I may be responsible for the full cost of the appointment if sufficient notice is not given.

I authorize release of my personal health information to and from Resolution Physiotherapy & IMS Clinic and my family Doctor’s office or family Dentist's office (whose names I have listed as part of client demographics).


Thank you for completing our intake questionnaire.

When you are finished, please click on 'done' and your information will be used to register you
with Resolution Physiotherapy & IMS Clinic.

We look forward to meeting you and showing you how effective our team of highly qualified Physiotherapists can be.

T