460 Main St, East. Unit M3 Hamilton, ON L8N 1K4 T: F:

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1 Page 1 of 6 Date Patient Information (Please complete all fields below) Last Name First Name Intl. Street Address Home Tel. City/Town Province Postal Code Work Tel. Date of Birth (mm/dd/yyyy) Gender M F Mobile Tel. Name of Emergency Contact Relationship Emergency Contact Tel. Name of Family Doctor Family Doctor Tel. Patient s Employer Occupation Case Information (Please complete all of the related information) Work Injury Date of Accident Claim Number Employer Occupation Phone Fax Primary Extended Health Care benefits coverage? Yes No (Please provide name of Insurance company) Certificate ID Policy Employee Name Date Of Birth Employer Name Employer Address Have you registered for Online billing? Yes No Secondary (spouse) Extended Health Care benefits coverage? Yes No (Please provide name of Insurance company) Certificate ID Policy Employee Name Date Of Birth Employer Name Employer Address Have you registered for Online billing? Yes No Other How did you hear about our clinic? Family Doctor Hospital Word of Mouth Advertisement Our Website Walk in Internet Other

2 Page 2 of 6 Patient Health History What is the main reason for your visit today? When did it start? Have you had this problem before? Yes No On a scale of 1-10 (10 is the worst) how severe is your pain? Have you ever had any of these treatments before for this problem? Chiropractor Acupuncture Massage Therapy Injections Physical Therapy Cane/Crutch Medical Doctor Do you currently experience any of the following? Fever Night Sweats Night Pain Weight Loss Loss of control of bowl/bladder None Have you ever been knocked unconscious? Yes No Have you ever broken any bones? Yes No Have you ever been in a car accident? Yes No Do you wear orthotics/arch supports? Yes No Have you had surgery in the past 5 years? Yes No Do you have allergies? Yes No Are you currently taking any medications? Yes No Current work status? Regular Light Duty (how long? ) Unemployed Not working due to this problem Retired Student Disabled

3 Page 3 of 6 Life Style: Are you currently a smoker? Yes packs/day No Have you ever smoked in the past? Yes, when did you quit? No Do you drink alcohol? None Occasional Frequent Do you exercise? Yes times per week for min/hour No Stress Level? Low Moderate High Have you ever been hospitalized overnight? Yes No Medical History: Peptic Ulcer Cancer Stroke High Blood Pressure Heart Disease Kidney Disease Diabetes Liver Disease Thyroid Disease Arthritis Asthma None Family History: Heart Disease Diabetes Cancer High Blood Pressure Arthritis Osteoporosis None Other Female Patients: Are you currently taking birth control pills? Yes No Have you ever taken birth control pills? Yes No Is there any chance you are pregnant? Yes No Number of pregnancies Number of children

4 Page 4 of 6 Accident description, please provide the following in the description: 1. How did the accident happen? Where did the accident take place? 2. Did you go to the hospital? 3. What part of the body did you injure and feel pain on right away? Patient Name: Patient Signature: Date: Date:

5 Page 5 of 6 Agreement Regarding Payment/Fee Services Patient Name (Please Print): Date of Injury: As a client receiving services from Main Street Health Recovery, I will consent that payment is to be made to Main Street Health Recovery. 1. Authorization to Pay: I hereby, authorize and direct WSIB to pay directly to Main Street Health Recovery, the medical expenses incurred by me for the assessments and treatment carried out at Main Street Health Recovery. These payments are to be made out to Main Street Health Recovery as payments towards the total charges for services rendered. 2. Benefits Information Release: I authorize the information pertaining to the benefits available to me or paid to me by my insurance company in regards to the above MVA to be released to Main Street Health Recovery. 3. Authorize to Direct Bill: I hereby authorize and direct Main Street Health Recovery to have expenses incurred by me at Main Street Health to be billed directly to WSIB. 4. Treatment Denial/Exceeding Treatment: I clearly understand and agree that I will be personally responsible for the outstanding balance, should WSIB deny my claim, or if I exceed my approved treatment. I authorize Main Street Health Recovery to bill to my Extended Health care, should my claim be denied. Patient s Name: Patient s Signature: Dated this day of, 20 Witness Name: Witness Signature: Dated this day of, 20

6 Page 6 of 6 Date: Dear Dr. Patient Name: Health Card No.: Family Doctor: I,, hereby request release of clinical information to Main Street Health Recovery for my rest results / medical history to facilitate quality and continuity of care. Please provide them with the latest test results for: 1. Diagnostic Imaging Results 2. Current Medications 3. Surgical History 4. Pre-existing Conditions within the last 5 years Please do not hesitate to contact our office for any further inquiries regarding this matter. If there is a fee involved please notify our office prior to sending records. Thank you for your assistance and cooperation in this matter. Thank you, Patient Signature: Witness Signature: Date: