Patient InformationFirst Name *Last NameEmail Address *Phone *Date of Birth *Street Address *Apartment, suite, etcCityState/ProvinceZIP / Postal CodeEmergency ContactFirst NameLast NamePhoneFamily Doctor InformationFirst NameLast NameStreet AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeMedical InformationCurrent Medications:Surgery:Injury:Have you received Physiotherapy or Massage before?YesNoHow long ago?Do you have any medical conditions? (e.g. High blood pressure, Diabetes, Heart disease, Osteoporosis, Allergies…)Insurance InformationInsurance CompanyPolicy / Group NumberID / Certificate NumberFirst Name (Policy Holder)Last Name (Policy Holder)Date of Birth (Policy Holder)Consent for payment and insurance billing *Yes, I agree with the privacy policy and terms and conditions. And I fully understand and expressly agree that I will be personally responsible for the full cost of services received from High Tech Physiotherapy. If I have insurance, I acknowledge it is my responsibility to keep track of my insurance coverage or request statements of account from High Tech Physiotherapy. If I incur any costs above and beyond my coverage, it is my responsibility to pay. If my insurance company allows electronic bill submissions, I consent for High Tech Physiotherapy to directly bill my insurance company online. I also consent for my insurance company to pay High Tech Physiotherapy directly. I consent for online submission *****If my claim is not instantly approved, but comes back pending or rejected. ****** I understand that I have 2 options. One is to pay in full or if I choose to wait for a response from the insurance I will leave a credit card on file. (A pending claim could be paid to the clinic or payment could go to you. In the case of the claim being paid to you, you are responsible to pay the clinic). If I have provided my Credit Card number and I authorize High Tech Physiotherapy to charge the Credit Card, if I do not turn over the funds within 4 weeks of the treatment date or within 7 days of a phone call from High Tech Physiotherapy. High Tech Physiotherapy reserves the right to add 4% monthly interest on unpaid balances until fully paid. I am fully aware that there is a 24 hour cancellation policy, and if I provide less than 24 hours notice, do not show up, or arrive late, High Tech Physiotherapy reserves the right to charge full price of the originally scheduled visit that was missed. I also understand it is my responsibility to keep track of my appointments.SubmitPlease do not fill in this field.
