Physiotherapy Home Visit Intake

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Name

First

Last

Date Of Birth

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone

Reason For Referral

Medical History - Please list any conditions that would impact the patients function or ability to perform physical activity.

Height (feet/inches)

Weight (lbs)

Initial Visit Within HRM est 45 min: $125

Follow Up Physiotherapist est 30 min: $100

Follow Up With Physiotherapist Assistant est 30 min: $60

Consent

I give consent to a physiotherapy assessment, billing at the the rates stated above and the use of electronic communications. Electronic communications are password protected but not 100% secure. All medical charts besides this form are kept by the therapist in written format at the clinic only and not shared electronically unless with express consent from the patient or legal guardian.

Any other comments or questions?

Signature - Full Name Of Patient Or Legal Guardian/POA