TRIANGLE PHYSIOTHERAPY & REHABILITATION

ORTHOTICS INTAKE FORM

Last Name: / First Name:

FILL OUT THE FOLLOWING SECTION ONLY IF YOU HAVE NEVER BEEN TO TRIANGLE PHYSIOTHERAPY BEFORE.

Date of Birth: / Gender: M F
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Referring Physician: / Telephone:

HOW DID YOU HEAR ABOUT US? (MARK ALL THAT APPLY)

I have been here before Doctor’s Referral Yellow Pages Book yp.ca Google search

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PLEASE FILL OUT THIS SECTION.

Weight: lbs Shoe size: What kind of shoes do you usually wear?

Do you have any pain or discomfort? Please describe.

CONSENT

I consent to be assessed and examined by a Registered Physiotherapist. I agree to abide by the policies in regards to orthotics outlined below.

Fees for GaitScan Assessment: $80.00. If orthotics are purchased, the fee for the GaitScan Assessment will be adjusted in the fee for the orthotics.

Fee for Orthotics: $550.00 including GaitScan Assessment.

Orthotics policy:

·  Orthotics can only be modified without a charge, 90 days from the date of manufacturing.

·  Major modifications within the 90-day period will be at an additional cost of $30.00.

·  All modifications beyond the 90 days will be at an additional cost of $30.00.

·  No refunds can be accommodated as they are custom made.

·  A doctor’s prescription will be required to claim the cost of the orthotics from the insurance.

·  It may take up to 4 weeks for the orthotics (new as well as modifications) to be delivered. ______(Initial here)

I have read the above & agree to pay for the services I have availed of at Triangle Physiotherapy. As the policy holder, it is my responsibility to contact my insurance company and confirm the exact details of my coverage. Insurance companies require proof of payment, therefore upfront payment is required. ______(Initial here)

CONSENT FOR PERSONAL INFORMATION

I understand that my personal information will solely be used to the extent necessary for the goods and services provided by Triangle Physiotherapy and will not be shared with any other party without my consent.I understand that by providing my email address I consent to Triangle Physiotherapy electronically communicating with me with regards to my appointments, occasional newsletters, greetings for birthdays & Christmas as well as to inform me of any promotions that may be of my interest.

Signature: Date:

Orthotics TP-012017 1