Acute Intake Form

Step 1 of 3

33%

Thank you for taking the time to fill out our intake form. Please note, filling out the form does not schedule an appointment. Booking an appointment can be done by calling (905) 631-0880.
General Information
Date of Birth
Date Format: MM slash DD slash YYYY
Sex
Your full name*
Address
Street Address City State / Province / Region ZIP / Postal Code
Home Phone*
Cell Phone
Email*
Occupation
How did you hear about us?
Other/Referral
Emergency Contact
Emergency contact phone number

Medical background
Medical doctor
Medical doctor phone number
Do you give us permission to contact your medical doctor regarding your health care?
List and known allergies
What is your main reason for treatment?

Privacy Policy
Privacy of personal information is important to Natural Care Clinic. We are committed to the collection, use, and disclosure of this information in a responsible way. We will also try to be open and transparent as to how we handle personal information.

Personal Information

Personal information is information about an identifiable individual. Generally, the information we collect is limited to your name, home contact information, gender, and age. As part of your patient file we retain your health history; health measurements and examination results; health conditions, assessment results and diagnoses; health services provided to you or received by you; your prognosis and other opinions formed; compliance with treatment; and the reasons for your discharge and discharge recommendations. We also maintain records for payment and billing purposes. Only necessary information is collected about you. We only share your information with you consent; the use, retention and privacy protection protocols. Privacy protocols comply with the privacy legislation, standards of our regulatory body, the College of Chiropractors of Ontario, and the law.

Staff Members

Staff members who come into contact with your personal information are aware of the sensitive nature of the information you have disclosed to us. They are all trained in the appropriate uses and protection of your information. These individuals include the clinic records personnel that control access to your patient file, therapists, clinic administration, and, when necessary, authorized individuals who may inspect our records as part of the regulatory activities in the public interest.

Disclosure of Personal Information

Our clinic understands the importance of protecting your personal information. To help you understand how we are doing that, we outline below how our clinics use and disclose this information:

1. To deliver safe and effective patient care
2. To enable us to contact you
3. To communicate with other health care providers
4. For teaching and demonstrating on an anonymous basis
5. To complete and submit claims on your behalf to third party payers
6. To process payments and collect unpaid accounts
7. For research purposes

By agreeing the consent sections of this form, you have agreed that you have given your informed consent to the collection, use, and/or disclosure of your personal information for the purposes that are listed. If a new purpose arises for the use and/or disclosure of your personal information, we will seek your approval in advance.

Patient Consent

I have review the about information that explains how the clinic may use my personal information. I agree Natural Care Clinic can collect, use, and disclose my personal information as set out above in the College’s privacy code.

Financial Policy

Payment, based on the discussed fee schedule, is due at the time services are rendered. Patients are responsible for their accounts. Our office does not file insurance claims for you, however will provide you with a receipt for you to submit for reimbursement. We do require 24 hours notice for cancelled appointments. Missed appointments will be charged 50% of the regular fee to the patient’s account.
*
- I have read and agree to the Privacy Policy

Step 1 of 3

General Information

Medical background

Privacy Policy