General Intake Form | Cogent Rehab

DEMOGRAPHICS & CONSENT FORM

Patient Information

Your First name

Your Last name

Your Gender

Your Date of Birth

Email

By providing your email, you are consenting to email communication from Cogent Physical Rehabilitation Center such as appointment reminders, statements, invoices, exercise instructions, newsletters & commercial electronic messages.

Cell Phone

Office Phone

Home Phone

Cogent Physical Rehabilitation Center staff may leave phone messages at provided numbers for confirmation or changes to your scheduled appointments. (Please check the phone numbers below if you do not want us to leave phone messages)

Do not Leave Phone Messages on These Number

Cell Phone

Home Phone

Office Phone

Address

City

Province

Postal Code

Emergency Contact Information

First Name

Last Name

Relationship

Phone Number

Family Physician Information

Physician Name

Physician Contact

Referral Information

Referring Physician

Check this if your were referred by your Family physician above.

Referring Physician's Name

Referring Physician's Phone

Referred by:

Check those that apply, or write in "Others" field here to the right :

If you are referred by Family, Friend or a Patient, who should we thank?

Name of Family, Friend or Patient

Information on About Your Visit

Reason For Visit

The health information requested on the following form will assist us in treating you safely. If you have any questions about the requested information, please feel free to ask.

Do you currently have or have you previously had any of the following conditions?

Do you currently have or have you previously had any of the following conditions?

For Women Only

Are you currently pregnant?

Yes

No

Have you experienced any of the following symptoms in the last one year?

Presenting Complaints

Please describe your symptoms of the present injury as best you can:

Does this condition interfere with your daily life? (If yes, please explain)

Cancellation and No-Show Policy

We are here to provide you with the very best care and attention. Your treatment time is reserved just for you. In our commitment to provide an outstanding experience to all our patients, and out of consideration for our physiotherapist’s time, we will be enforcing a cancellation and no-show policy. A minimum of 24 hours is required for cancellations or a $50.00 cancellation fee will be charged to your account. As a courtesy to our patients, if you arrive late, your appointment will be shortened

to the remainder of your original scheduled appointment.

Physiotherapy Consent:

Physiotherapy involves many different types of physical evaluation and treatment. As with all forms of medical treatment, there are benefits and risks involved with physiotherapy. The physical response to treatment varies and cannot always be predicted as every individual is different. There is no guarantee that the treatment will help the condition you are seeking treatment for and there is a risk that treatment will cause some discomfort or aggravation of the existing condition.

During your physiotherapy visit, it is often necessary to expose and touch the area in need of treatment. At times, the practitioners may ask you to remove some items of clothing to facilitate treatment. If you do not feel comfortable with any part of the treatment, please tell us immediately. Every effort is made to preserve modesty and keep you comfortable.

Please communicate to your therapist and the operations manager if you have any other concerns during the treatment. Physiotherapy, as with any type of medical care, is the most effective if you participate according to the treatment plan agreed upon with your therapist. If at any time

you have questions regarding treatment and services provided, please do not hesitate to talk to your therapist.

By signing this, I hereby:

● Authorize the release of all necessary information to my primary care provider and/or referring physician.

● Understand the cancellation policy and acknowledge the potential charges for late cancellations or no-shows.

● Have read this form and agree to all consent regarding physiotherapy evaluation and treatment.