Client Intake Form - Resolution Physiotherapy & IMS Clinic

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

Surname

First Name

Date of Birth (mm/dd/yyyy)

Question Title

* 2. Please choose the primary area of your pain or dysfunction.
Although our Physiotherapists often treat multiple issues within an appointment, please choose only one option.

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

* 3. Contact Info

Apartment

Street

City

Province

Postal Code

Home Phone

Cell Phone

Question Title

* 4. Do you have extended benefits coverage?

YES

Question Title

* 1. Client

Question Title

* 2. Please choose the primary area of your pain or dysfunction. Although our Physiotherapists often treat multiple issues within an appointment, please choose only one option.

Question Title

* 3. Contact Info

Question Title

* 4. Do you have extended benefits coverage?

* 2. Please choose the primary area of your pain or dysfunction.
Although our Physiotherapists often treat multiple issues within an appointment, please choose only one option.