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General Client Information and Consent
Please complete these forms prior to your first visit
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* Indicates required question
Email
*
Your email
Permission to receive emails (By selecting yes, we can send you appointment reminders and clinic updates)
*
Yes please
No thank you
Required
What is your First and Last Name?
*
Your answer
Gender
*
Male
Female
Prefer not to say
Non-Binary
Required
Date of Birth
*
MM
/
DD
/
YYYY
Do You Have Extended Healthcare (Benefits)?
*
Yes, my own
Yes, under spouse/parent
No
Required
Address (Street, City, Province, Postal Code)
*
Your answer
Preferred Contact Phone Number
*
Your answer
Cell Phone Number If Different Than Preferred
Your answer
Emergency Contact - Please provide us with someone we can call in case of emergency. Please include a name and phone number
*
Your answer
Family Doctor / Nurse Practitioner
Your answer
Referring Doctor / Nurse Practitioner
Your answer
How did you find out about us?
*
Choose
Website
Advertising
Google
Yellow Pages
Family Doctor
Hospital/Emergency Department
Orthopedic Surgeon
Family/Friends
Word of Mouth
Returning Client
Insurance Company
Other
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