We will be opening our doors to in-person services on June 1, 2020. Please confirm timings/protocols for each location prior to coming in for appointment.
PATIENT
Location Mississauga - MillcreekMilton
First Name
Middle Name
Last Name
Date of Birth
Gender MaleFemale
Marital Status SingleMarriedDivorcedCommon LawWidowed
Home Address
Home Phone Number
Cell Phone Number
Work Phone Number
Email Address
Employer's Name
Occupation
Employer's Address
INSURANCE***FILL IN THIS PART IF INSURANCE DOES DIRECT BILLING*** If No Direct Billing, Pay Upfront
Relationship to Patient
Insurance Name
Policy Number
Certificate Number
If this is a Work Related Injury (WSIB) or Auto Accident Injury, please provide details below:
Claim Number
SIN Number
Adjuster's Name
OHIP Number
EMERGENCY CONTACT
Contact Phone Number
MEDICAL HISTORY
Family Doctor's Name
City
Doctor's Office Phone Number
What is the reason for your visit? Auto AccidentWork Related Injury (WSIB)Other
If other, please specify:
Did you seek medical attention after the injury? YesNo
If yes, please specify:
Please describe your pain: BurningDull AchinessPin/NeedlesNumbnessStabbingOther
Date of Injury
Have you taken X-rays for this injury? NoYes
Have you had any Hospitalization/Surgeries for this injury? NoYes
Current Medications
Please check the conditions that apply to you: ArthritisAsthmaBlood ClotsCancerCardiac DisorderCirculation DisorderCurrently PregnantDiabetesDizzinessEpilepsyEmphysemaHead InjuryHeart AttackHigh Blood PressureLow Blood PressureMetal ImplantsMigrainesNeurological DisorderPulmonary DisorderStrokeOther
Where did you hear about us?
Date of Service
CONSENT FOR TREATMENT:
I HEREBY ASSIGN ALL MEDICAL BENEFITS TO WHICH I AM ENTITLED TO THE HEALTH FIRST GROUP, IN THE EVENT THEY FILE INSURANCE ON MY BEHALF. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES WHETHER OR NOT PAID BY STATED INSURANCE. IN THE EVENT MY ACCOUNT BECOMES DELINQUENT AND IS THEREFORE IN DEFAULT OF PAYMENT, I ACCEPT RESPONSIBILITY FOR THE PRINCIPAL AMOUNT OWING AS WELL AS ALL REASONABLE COSTS ASSOCIATED WITH THE COLLECTION OF THIS DEBT. THIS INCLUDES, BUT IS NOT LIMITED TO, COLLECTION SERVICE FEES, ATTORNEY’S FEES, AND ALL COURT COSTS AND ADDITIONAL LEGAL FEES ASSICIATED WITH THE RECOVERY OF THIS DEBT. *
I HEREBY AUTHORIZE THE HEALTH FIRST GROUP TO RELEASE ALL INFORMATION NECESSARY TO SECURE THE PAYMENT OF SAID BENEFITS. A COPY OF THIS CONSENT SHALL BE CONSIDERED AS EFFECTIVE AND VALID AS THE ORIGINAL.
I DO HEREBY CONSENT TO IN-PERSON TREATMENT OR VIRTUAL TREATMENT BY THE AUTHORIZED PERSONNEL OF THE HEALTH FIRST GROUP. I ALSO UNDERSTAND THAT THE HEALTH FIRST GROUP WILL NOT DISCLOSE ANY PERSONAL INFORMATION EXCEPT TO THOSE THAT ARE PERMITTED, SUCH AS MEDICAL/HEALTHCARE PRACTIITIONER, FAMILY PHYSICIAN, APPOINTED GUARDIAN OR REPRESENTATIVE, LAWYER, WSIB PERSONNEL, OR EMPLOYER. THIS CONSENT IS INTENDED AS A WAIVER OF LIABILITY FOR SUCH TREATMENT EXCEPTING ACTS OF NEGLIGENCE. THE CONSENT BECOMES BINDING WHEN DIGITIALLY SIGNED:
Patient Name
Patient Signature
*IN THE EVENT THAT AN APPOINTMENT IS MADE AND NOT CANCELLED WITHIN 24 HOURS, OR IS MISSED A TREATMENT FEE WILL BE APPLIED TO MY ACCOUNT OR THE SESSION WILL BE CHARGED TO YOUR INSURANCE.* *****ACCOUNTS OVERDUE FOR 60 DAYS & RETURNED CHECKS WILL GO TO COLLECTIONS*****
