*FEEL FREE TO ASK YOUR LASER THERAPIST THE TOTAL COST OF YOUR TREATMENT PRIOR TO INITIATION.
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1 FEE SCHEDULE & POLICY (OHIP) Meditech Rehabilitation Centres Inc. provides the following services: Updated: 19Oct17 1. Laser Therapy 2. Massage Therapy 3. Physiotherapy 4. Chiropractic Therapy 5. Exercise Programs The majority of these therapeutic applications are not covered by OHIP. Private insurance plans, however, may cover some of the services listed above. It is always the responsibility of the patient to pay for treatments provided on the date when these were rendered. The patient, at their discretion, should submit the claim to their insurance carrier for reimbursement. Initial consultations by physicians are generally covered by OHIP for patients who are Canadian citizens. Occasionally, billing carried out by your family physician and Meditech Rehabilitation Centers Inc. may occur on the same day and one health care professional will not be compensated for the services rendered. Visits on the same day should therefore be avoided. Laser Therapy: (Not covered by OHIP) Massage Therapy: $ for 30 minutes for EACH SYSTEM utilized $60.50 (30 minutes) $ for 45 minutes $82.50 (45 minutes) $ for 60 minutes $ (60 minutes) *If multiple conditions/areas are being treated at the same time, the number of minutes per system will be totaled to determine cost. (e.g. Both knees treated for 30 mins will be charged $110.00) $ (90 minutes) *Any massage missed or cancelled with less than 24 hours notice will be charged at full price for service *FEEL FREE TO ASK YOUR LASER THERAPIST THE TOTAL COST OF YOUR TREATMENT PRIOR TO INITIATION. Physiotherapy: Chiropractic Therapy: $60 Initial Assessment $60.00 Initial Assessment $30 Follow up assessment $30.00 Follow up assessment For patients who prefer privacy, the VIP Room will be available at an additional charge of $10.00 per visit. NOTE: Appointments must be booked in advance Health Insurance Coverage : If you have extended health care benefits, you may be covered under Physiotherapy and/or Chiropractic benefits. Depending upon your specific insurance plan the laser treatments may be covered when therapy is carried out under the supervision of, Nathan Cheung D.C. and David Kunashko D.C., the chiropractors on staff and/or Amr El Gabry, the Registered Physiotherapist. Please check with your insurer to determine your coverage and advise us accordingly (i.e. maximum per year and allowance per visit). Payment We accept the following: VISA, MasterCard, AMEX, Debit, Cash, or Personal Cheque. Kindly check one box: ם Provide us with your credit card number and expiry date below for pre authorized payment. ם Pay after each treatment and you may leave your credit card number and expiry date below for security purposes only. I hereby authorize Meditech International Inc. to charge my credit card: # expiry date / In the name of for any unpaid charges. From time to time I understand that Dr. F. Kahn may make referrals to Meditech Laser Rehabilitation Centre. I further understand that Dr. F. Kahn has an ownership interest in this rehabilitation centre. I,, have read the above and fully understand Meditech Laser Rehabilitation Centre's fee schedule & policy and agree to abide by it. Date Patient Signature
2 PATIENT INFORMATION SHEET Name: Sex: M / F Date: Address: City: Province: Postal Code: Home Phone #: Date of Birth: Work Phone # / Other #: Dr. s Name & Ph. #: Health Card #: HOW DID YOU HEAR ABOUT US? Current Health Habits Yes No Patients Comments Doctor s Comments Did/do you smoke? Did/do you drink any alcohol? Are you concerned about your diet? Have you been in accidents? Current medications? How Long? Allergies? Exercise regularly? Sleeping posture side stomach back Females: Are you pregnant? Did/do you have cancer? Type? Is there a family history of: Heart Disease Arthritis Cancer Diabetes Other Present Complaint: Pain or problem started on Pains are: Sharp Dull Constant Intermittent What activities aggravate your condition/pain? What activities lessen your condition/pain? Is condition worse during certain times of the day? Is this condition interfering with your: Work? Sleep? Daily Routine? Other? Is condition getting progressively worse? Have you seen any other Doctors for this condition? Any effective treatments? Have you experienced any side effects from the drugs and surgeries? Other Symptoms: Headaches Fatigue Visual Disturbances Depression/Anxiety Sleeping Problems Memory Loss Back Pain Fainting Episodes Feelings of Stress Loss of Smell Irritability Loss of Taste Chest Pain Gastrointestinal Disturbances Pins and Needles Sensations Ataxia Numbness and Tingling Tinnitus Shortness of Breath
3 PATIENT PAIN ASSESSMENT Name: Last First Date 0 10 Numeric Pain Intensity Scale (1) No Mild Moderate Severe Very Intolerable Pain Pain Pain Pain Severe Pain 1) Please rate your pain by circling the one number that best describes your pain at its WORST in the past 24 hours. 2) Please rate your pain by circling the one number that best describes your pain at its LEAST in the past 24 hours. 3) Please rate your pain by circling the one number that best describes your pain on the AVERAGE. 4) Please rate your pain by circling the one number that tells how much pain you have RIGHT NOW. 5) What treatments or medications are you receiving for your pain? 6) Circle the one number that describes how, during the past 24 hours, pain has interfered with your: A. General activity B. Walking ability C. Normal work (includes both work outside the home and housework) D. Sleep E. Enjoyment of life
4 CONSENT TO LOW INTENSITY LASER TREATMENT Low Intensity Laser Therapy (LILT) consists of the use of monochromatic light emission from a Low Intensity Laser Diode (250 milliwatts or less) or an array of high intensity Super Luminous Diodes (providing optical power in the milliwatt range) to treat musculoskeletal injuries, chronic and degenerative conditions and to heal wounds. The light source is placed in contact with the skin allowing the photon energy to penetrate tissue, where it interacts with various intracellular biomolecules resulting in the restoration of normal cell morphology, function and the enhancement of the body s healing processes. Low Intensity Laser Therapy improves/cures multiple pathologies with the following objectives in mind, i.e.: 1. Elimination of pain. 2. Reducing or obviating dependence on pharmaceuticals. 3. Restoration of mobility (normal range of motion). 4. Improve quality of life (activity levels, sleep, etc.) 5. Remove the need for surgical intervention in many situations. Treatments are usually scheduled 2 3 times per week or more frequently in acute cases, at least initially. Subsequent treatments are scheduled in accordance with the patient s physical status. With regard to the number of treatment sessions, these may vary from 1 to 30. A minimum of 5 treatments is recommended. It is important to be aware that before treatment is initiated that the exact number of treatments cannot be predicted. In most cases we expect to see some change in symptomology after 3 5 sessions. There are however exceptions to this rule. Acute injuries generally respond more rapidly than chronic problems and each individual s tissue response varies. Please do not forget that our objective is to minimize the length of treatment and the number of visits. On occasion, however, even our best efforts require multiple treatments, patience and time. The risk of complications from LILT treatment is substantially less than that associated with many other treatments, medications, and procedures available for the same conditions. It is the practice of our institution to inform patients with regard to these and other matters. Some patients have experienced exacerbation of pain or fatigue subsequent to treatment. If this occurs, utilize pain medication, and/or ice on the area of involvement and notify the doctor/therapist prior to the next treatment. The existence of this phenomenon is due to a sensitive tissue response and protocols will be adjusted accordingly on your next visit. A dull aching sensation subsequent to treatment lasting less than 24 hours indicates that your tissues are reacting positively on the cellular level. Contraindications to treatment include: first trimester of pregnancy and patients on photo sensitive medications. Laser does not cause cancer, has no cytogenic effect and does not damage tissues. I acknowledge that I have discussed, or I have had the opportunity to discuss, with my doctor the nature, purpose and procedures of LILT treatment in general, my treatment in particular, alternative treatments and procedures, material risks of those treatments and procedures, the corresponding fee schedule as well as the contents of this consent form. I understand that my clinical information maybe used as part of a clinical study. I hereby give my full consent and permission to use this information solely for the purpose stated. I consent to the low intensity laser treatments offered or recommended to me by my doctor. I intend this consent to apply to all my present and future low intensity laser treatments. Date Patient Signature/Legal Guardian Guardian Relationship to Patient Printed Name
5 PATIENT COMPLIANCE THERAPEUTIC IMPLICATIONS At this time, we wish to emphasize a number of factors regarding the administration of Laser Therapy. The therapy team that attends to your medical problems will advise you regarding the frequency and duration of treatments. This may vary from one patient to another and also with respect to the condition being treated. For travel and work reasons deviations from the treatment schedule are permissible. Generally, however, patients are advised to follow the course of treatment outlined, in order to produce optimal clinical outcomes. Significant deviation from that course can impede the healing process. Our experience over the course of almost twenty years has proven conclusively that patients who comply with their prescribed therapeutic schedule achieve their objectives more rapidly than those who do not. Once again, in order to achieve maximum benefit, patients must be encouraged to follow the treatment schedule outlined by the healthcare professional managing their case. Allowances with regard to frequency of treatments may be made depending on geographic considerations and the time factor involved. For best outcome however, a relatively structured therapeutic programme is essential. In some patients, improvement may be evident after only 1 2 treatment sessions, in others however, secondary to genetic factors, chronicity, etc treatments may be required before significant improvement is experienced. It is always stressed that patients should adhere to the programme recommended, in order to achieve the desired objective. Adverse effects resulting from Laser Therapy are negligible and are not significant in our extensive experience. Nevertheless, if any should occur bring them to the immediate attention of the medical staff in order that the therapy may be modified accordingly. It is essential that patients be reassessed by the healthcare professional directing their therapeutic programme every 2 4 visits, to effect protocol changes that will advance the healing process. Customization of the protocols for each individual patient is an important aspect of Laser Therapy. If patients need to be seen more frequently by the supervising clinician, they should so indicate when registering or notify the attending therapist, prior to the initiation of treatment. Fred Kahn, M.D., F.R.C.S.(C)
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Name First Middle Initial Last Today s Date. Address Street City State Zip. Primary Phone # Cell # . Your Occupation Employer
Name First Middle Initial Last Today s Date Address Street City State Zip Date of Birth Age Social Security # Sex: Male Female mm/dd/year Primary Phone # Cell # Email Emergency Contact Name Number Marital
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Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No
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Health for Life Chiropractic At Cloverdale Mall Unit #143-250 The East Mall Etobicoke, ON, M9B 3Y8 416-232-1822 416-232-0060 Dr. Chrystopher Sly B.Sc, D.C. Dr. Jesse Cracknell B.A., D.C. Adult Health Questionnaire
Patient Information (please print clearly) Name: Date of Birth: mm/dd/yyyy / / Age: (to receive appointment reminders)
YOUR HEALTH Wellness Centre 1158 Winston Churchill Blvd Oakville, ON L6J 0A3 Chiropractic New Patient Form Patient Information (please print clearly) Name: Date of Birth: mm/dd/yyyy / / Age: Address: City:
CHIROPRACTIC NEW PATIENT HEALTH HISTORY
CHIROPRACTIC NEW PATIENT HEALTH HISTORY Name: Last: First: MI: Address: City: Province: Postal Code: E-mail address: Cell Phone: Home Phone: Age: Birth Date: Alberta Health #: Occupation: Employer: Marital
Patient Information. Preferred Name: Date of Birth: SSN: Address: City: State: Zip: Phone: Cell/Home/Work (please circle one)
Patient Information Name: First Last M.I. Date: Preferred Name: Date of Birth: SSN: Address: City: State: Zip: Email: Phone: Cell/Home/Work (please circle one) How did you hear about us? Door hanger, Fargo
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New Patient Intake Form Date: / / Patient s Full Name E-Mail: Home Phone: Cell: Male Female Age: Date of Birth: / / Social Security # - - Mailing Address: City: State: Zip: Married Single Widowed Separated
Pregnant Patient Introduction Form Form
1820 S. Westnedge Ave. Suite #1. Kalamazoo, MI 49008 269.344.5551 antoniottichiropractic.com Form : Patient name: Address: Estimated Due : Home Phone: INTRODUCTION MEDICAL HISTORY City, State, Zip: Work
Name Date / / Age Male/ Female Address City State Zip
T 1 2 3 : Name _ Date / / Age Male/ Female Address City State Zip Phone: Home Cell Cell Phone Provider Email Address Date of Birth / / Occupation Employer Single / Married / Divorced / Widowed Spouse s
Rupp Chiropractic FAMILY PHYSICIAN FEMALES: ARE YOU PREGNANT, OR A CHANCE YOU MIGHT BE PREGNANT? YES / NO HOW WERE YOU REFERRED TO OUR OFFICE?
PATIENT INFORMATION NAME DATE ADDRESS CITY STATE ZIP HOME # CELL # WORK # E MAIL ADDRESS SOCIAL SECURITY # I WOULD LIKE TO RECEIVE EMAIL APPOINTMENT REMINDERS [YES] [NO] RACE: AMERICAN INDIAN ALASKA NATIVE
PATIENT NAME DATE CONSULTATION QUESTIONNAIRE
CONSULTATION QUESTIONNAIRE 1. What is your major symptom? 2. What does this prevent you from doing or enjoying? 3. If this is a recurrence, when was the first time you noticed this problem? How did it
Matthews Family Chiropractic
Dr. John J. Hanna, Director Matthews Family Chiropractic Windsor Square 9808 Northeast Parkway Matthews, NC 28105 (704) 845-0699 CASE HISTORY PLEASE PRINT Name: Home Phone: Address: City: Zip: Page 1 Age:
PERSONAL INFORMATION. Date of Birth Age (Last) (First) (M.I.) Address City/State Zip. Phone # Home Work Cell
*If the reason for your visit is due to a worker s compensation injury or an automobile accident, please inform the front desk immediately. PERSONAL INFORMATION of Birth Age (Last) (First) (M.I.) Address
Chiropractic Case History/Patient Information
1 Chiropractic Case History/Patient Information Name: Social Security # Home Phone: Address: City: State: Zip: E-mail address: Cell Phone: Age: Birth Date: Race: Marital Status: [M] [S ][W] [D] Occupation:
Please fill out the following form in as much detail as possible. Please Print. Name. Address. City State Zip. Home Phone Office Phone.
CASE NO. Please fill out the following form in as much detail as possible. Please Print Date Name Address City State Zip Home Phone Office Phone E-mail Address Age Date of Birth Occupation Sex (M) (F)
SMITH CHIROPRACTIC HEALTH PROFILE Today s Date:
SMITH CHIROPRACTIC HEALTH PROFILE Today s Date: Name: Age: Male/Female DOB: Address: City: State: Zip: Home Phone:_ Cell: Cell Phone Provider: SSN#: Email Address: Single/Married/Divorced/Widowed Spouse
SPORTS AND SPINE PHYSICAL THERAPY, INC. PATIENT MEDICAL HISTORY
SPORTS AND SPINE PHYSICAL THERAPY, INC. PATIENT MEDICAL HISTORY Name: Referring Physician: How did you hear about Sports and Spine Physical Therapy? First date of onset of pain: Have you had surgery for
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Fax to: 972-393-4200 Email to: denise@points4health.com Points of Health & Herbal Medicine Denise Edmiston, L.Ac., LCSW 413 W. Bethel Rd., Suite 202 Coppell, Texas 75019 P-(972)506-8113 F(972)393-4200
Welcome to our practice! Please help us serve you better by taking a few minutes to provide the following information.
203-610-2681 New Patient Intake Form Welcome to our practice! Please help us serve you better by taking a few minutes to provide the following information. Name: Last Name First Name Today s date: Address:
PATIENT APPLICATION FORM
PATIENT APPLICATION FORM WELCOME and THANK YOU for applying as a patient in our clinic. We are a very unique team specializing in researched-based spinal and postural rehabilitation. These methods have
arah s CLIENT INFORMATION M A S S A G E T H E R A P Y
1 arah s M A S S A G E T H E R A P Y CLIENT INFORMATION Please take care to fill out this form thoroughly and carefully. The information will help your massage therapist provide optimal care. Your cooperation
Chiropractic Case History/Patient Information
1 Chiropractic Case History/Patient Information Name: Social Security # Home Phone: Address City: State: Zip: E-mail address: Fax # Cell Phone: Age: Birth Race: Marital: M S W D Occupation: Office Phone:
Dr. Fawn Shaffer, DC 565 McElhattan Drive Lock Haven, PA (570)
PATIENT Dr. Fawn Shaffer, DC 565 McElhattan Drive Lock Haven, PA 17745 (570) 748-3590 PERSONAL INFORMATION: Please Circle: Mr. Mrs. Ms. Miss Dr. Male Female Name: Nickname: Age: DOB: Address: City/State/
WELCOME to the Florence Chiropractic and Wellness Center.
WELCOME to the Florence Chiropractic and Wellness Center. Thank you for choosing our practice for your chiropractic and wellness needs. Please complete this form in ink. If you have any questions or concerns,
Application for Patient
Application for Patient First Name: M.I.: Last Name: Date: Address: City: State: Zip: SS#: - - Age: DOB: / / Male / Female Email: Home #: Cell # Work # Primary Care Physician: Do we have permission to