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Book Your Telehealth Appointment
We’re so glad you’re here. Please fill out the form below to help us understand your needs. All information is private and will be sent directly to the physiotherapist.
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Email
*
Your email
PERSONAL INFORMATION
Full name:
*
Your answer
Preferred Name (if different):
Your answer
Date of Birth:
*
MM
/
DD
/
YYYY
Preferred Contact Method:
*
Email
Phone
Text Messages
Required
Email Address:
*
Your answer
Phone Number:
*
Your answer
Are you a British Columbian Resident?
*
Choose
Yes
No
If not, where do you reside?
Choose
Yes
No
ABOUT YOU
What brings you to our pelvic health / chronic
pain
virtual
clinic?
Your answer
When did your symptoms begin?
Your answer
Have you had any previous treatment or diagnosis related to this concern?
Your answer
Do you have any relevant medical history (e.g., surgeries, childbirth, chronic conditions)?
Your answer
YOUR EXPERIENCE WITH TECHNOLOGY
Are you familiar with telehealth (virtual care)?
Yes
No
Somewhat
Clear selection
Have you done a video call before (Zoom, Google Meet, etc.)?
Yes
No
Clear selection
Do you feel confident using a computer, tablet, or smartphone for a video call?
Yes
No
I might need a little help
Clear selection
Do you have access to:
*
A private space for sessions
A stable internet connection
A device with a camera and microphone
Required
What device do you plan to use for the session?
Choose
Computer
Tablet
Smartphone
Not sure yet
HOW CAN WE SUPPORT YOU?
What are your goals for physiotherapy?
Your answer
Do you have any concerns or questions you'd like to share before we meet?
Your answer
Thank you for taking the time to complete your form.
We truly appreciate it. We'll be in touch with you soon to gently guide you through the next steps and book your appointment. We're here to support you every step of the way.
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