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Looking for the Best Physical Rehab?

Call : +1 (416) 249-8668

Email :info@trinityrehab.ca

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About Us
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FAQ

About Us
- Who We Are
- Our Team
- Careers
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Services
- Core Services
- What We Treat
Patient Center
Contact Us
Blogs

Looking for the Best Physical Rehab?

About Us
Our Services
Patient Center
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Contact Us
FAQ

About Us
Our Services
Patient Center
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Contact Us
FAQ

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TPh. 416-249-8668, Fax. 416-249-5794, Email:info@trinityrehab.ca
1 723 Kipling Ave. Unit#9, Etobicoke, ON M9R4E1
www.Trinityrehab.ca

MVA PATIENT INTAKE

PERSONAL INFORMATION

Last Name:

Address: (Unit & Street ):

Gender:

Cell #:

Family Physician:

Emergency Contact Telephone #:

I agree to receive e-newsletter and pro- motions via email:

Yes

No

First Name:

City:

E-mail:

Send Appointment reminder:

Yes

No

Physician Fax #:

How did you hear about us?:

Date of Birth:

Postal Code:

Telephone #:

Email:

Emergency Contact Full Name:

Referral Name or Source:

EXTENDED HEALTH INFORMATION

Do you have Extended Health Care Coverage?:

Yes

No

Do your parent(s) have Extended Health Care Coverage?:

Yes

No

Does your spouse have Extended Health Care Coverage?:

Yes

No

If you have checked off being covered under more than one persons benefits, please request a Secondary Coverage Form from us:

Yes

No

Insurance Company Name:

Telephone #:

Policy Holder’s Date of Birth (YYMMDD):

Plan / Policy #:

Fax #:

Group / ID #:

Policy Holder’s Name:

Types Of Services

Types Of Services:

Chiropractic

Physiotherapy

Massage therapy

Acupuncture

Custom Orthotics/ Orthopaedic Shoes

Compression Stockings

Back support/Pillow

Osteopathy

TENS Machine

Braces

Chiropractic service

Chiropractic Coverage:

Chiropractic Referral MD/DC:

Chiropractic % per visit:

Chiropractic Benefit year:

Chiropractic Visit Max Covered:

Chiropractic Notes (Deductivle):

Physiotherapy service

Physiotherapy Coverage:

Physiotherapy Referral MD/DC:

Physiotherapy % per visit:

Physiotherapy Benefit year:

Physiotherapy Visit Max Covered:

Physiotherapy Notes (Deductivle):

Massage therapy

Massage therapy Coverage:

Massage therapy Referral MD/DC:

Massage therapy % per visit:

Massage therapy Benefit year:

Massage therapy Visit Max Covered:

Massage therapy Notes (Deductivle):

Acupuncture

Acupuncture Coverage:

Acupuncture Referral MD/DC:

Acupuncture % per visit:

Acupuncture Benefit year:

Acupuncture Visit Max Covered:

Acupuncture Notes (Deductivle):

Custom Orthotics/ Orthopaedic Shoes

Custom Orthotics/ Orthopaedic Shoes Coverage:

Custom Orthotics/ Orthopaedic Shoes Referral MD/DC:

Custom Orthotics/ Orthopaedic Shoes % per visit:

Custom Orthotics/ Orthopaedic Shoes Benefit year:

Custom Orthotics/ Orthopaedic ShoesVisit Max Covered:

Custom Orthotics/ Orthopaedic Shoes Notes (Deductivle):

Compression Stockings

Compression Stockings Coverage:

Compression Stockings Referral MD/DC:

Compression Stockings % per visit:

Compression Stockings Benefit year:

Compression Stockings Visit Max Covered:

Compression Stockings Notes (Deductivle):

Back support/Pillow

Back support/Pillow Coverage:

Back support/Pillow Referral MD/DC:

Back support/Pillow % per visit:

Back support/Pillow Benefit year:

Back support/Pillow Visit Max Covered:

Back support/Pillow Notes (Deductivle):

Osteopathy

Osteopathy Coverage:

Osteopathy Referral MD/DC:

Osteopathy % per visit:

Osteopathy Benefit year:

Osteopathy Visit Max Covered:

Osteopathy Notes (Deductivle):

TENS Machine

TENS Machine Coverage:

TENS Machine Referral MD/DC:

TENS Machine % per visit:

TENS Machine Benefit year:

TENS Machine Visit Max Covered:

TENS Machine Notes (Deductivle):

Braces

Braces Coverage:

Braces Referral MD/DC:

Braces % per visit:

Braces Benefit year:

Braces Visit Max Covered:

Braces Notes (Deductivle):

AUTOMOBILE INSURANCE INFORMATION

Insurance Company Name:

Telephone #:

Policy #:

Date of Issue of Policy:

City or Town of Branch Office (if applicable):

Fax #:

Claim #:

Were you at fault for the accident?

Yes

No

Adjuster’s Name:

Date of Accident (YYMMDD):

Name of policy holder same as:Applicant/OR

WORK INFORMATION

Employer:

Work Telephone #:

Occupation:

Work Fax #:

LEGAL INFORMATION

Law Firm:

Fax #:

Legal Representative:

Email:

Telephone #:

ACCIDENT PROFILE

Patient’s Name:

Date:

Were you working at the time of the accident?

Yes

No

Type of vehicle:

Date of Accident:

Amount of Damage:

Location of Accident:

How did the accident happen?

Were you wearing your seatbelt? Helmet if on bike or motorcycle?

Yes

No

Did you hit your head? If yes, where?

Yes

No

Where:

Were you able to exit the vehicle independently? If no, how did you exit?

Yes

No

how did you exit?

Did the ambulance arrive?

Yes

No

If yes, were you transported to hospital?

Did the airbags deploy?

Yes

No

Did you hit any other part of your body inside the vehicle? If yes, where?

Yes

No

Where:

Were you bleeding?

Yes

No

Did the police arrive?

Yes

No

Were you wearing your seatbelt? Helmet if on bike or motorcycle?

Yes

No

Did you lose consciousness? If yes, how long?

Yes

No

How long?:

Any nausea or vomiting after accident?

Yes

No

Was an accident report filed?

Yes

No

TREATMENT RECEIVED

DID YOU VISIT THE FOLLOWING?Please Select Both Checkbox.

Hospital

Family Physician

HOSPITAL

Date:

Name of Doctor:

Other:

Name / Location:

Findings:

Name of Doctor:

Prescribed Medications:

Family Physician

Date:

Name of Doctor:

Other:

Name / Location:

Findings:

Name of Doctor:

Prescribed Medications:

Have you received treatment at any other therapy clinic for this accident?

Yes

No

End Date:

Did you feel better after the treatment already received?:

*Name

Frequency:times / week

Translation needed:

Yes

No

Start Date:

Type of therapy:

Chiropractic

Physiotherapy

Massage o Exercises

Comments:

I hereby certify that I have read and understand the information recorded and verify that it is true and accurate.

Patient’s Signature:

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